Provider Demographics
NPI:1487410742
Name:SUN, VIVIAN (MS, RD, CDN)
Entity type:Individual
Prefix:MS
First Name:VIVIAN
Middle Name:
Last Name:SUN
Suffix:
Gender:F
Credentials:MS, RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 BEACON HILL RD
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-3035
Mailing Address - Country:US
Mailing Address - Phone:516-888-7152
Mailing Address - Fax:
Practice Address - Street 1:67 BEACON HILL RD
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050-3035
Practice Address - Country:US
Practice Address - Phone:516-888-7152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003855133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist