Provider Demographics
NPI:1699450858
Name:SULLIVAN, SHANNON MOIRA (RD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MOIRA
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W SAINT ELMO RD APT 1007
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-3316
Mailing Address - Country:US
Mailing Address - Phone:254-290-2183
Mailing Address - Fax:
Practice Address - Street 1:8700 MENCHACA RD STE 806
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-5379
Practice Address - Country:US
Practice Address - Phone:254-290-2183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT86901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered