Provider Demographics
NPI:1235020983
Name:SULLIVAN, BONNIE A (RDN)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:A
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4622 WINDSWEPT DR
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48380-2777
Mailing Address - Country:US
Mailing Address - Phone:989-928-6197
Mailing Address - Fax:989-928-6197
Practice Address - Street 1:4622 WINDSWEPT DR
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MI
Practice Address - Zip Code:48380-2777
Practice Address - Country:US
Practice Address - Phone:989-928-6197
Practice Address - Fax:989-928-6197
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-11
Last Update Date:2025-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1037397133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered