Provider Demographics
NPI:1124529664
Name:SULLIVAN, CHRISTINE M (MA, RD, LDN)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MA, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 LOMBARD ST APT 307
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-1543
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:93 OLD YORK RD STE 1732
Practice Address - Street 2:
Practice Address - City:JENKINTOWN
Practice Address - State:PA
Practice Address - Zip Code:19046-3925
Practice Address - Country:US
Practice Address - Phone:888-406-8388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-21
Last Update Date:2024-08-05
Deactivation Date:2020-03-26
Deactivation Code:
Reactivation Date:2024-08-05
Provider Licenses
StateLicense IDTaxonomies
PADN005734133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered