Provider Demographics
NPI:1215773031
Name:SULLIVAN, LUCY MACKINNON
Entity type:Individual
Prefix:
First Name:LUCY
Middle Name:MACKINNON
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6630 81ST ST
Mailing Address - Street 2:
Mailing Address - City:CABIN JOHN
Mailing Address - State:MD
Mailing Address - Zip Code:20818-1205
Mailing Address - Country:US
Mailing Address - Phone:410-980-2924
Mailing Address - Fax:
Practice Address - Street 1:4820 31ST ST S STE B
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22206-1665
Practice Address - Country:US
Practice Address - Phone:703-865-6490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD86300512133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered