1528115755 NPI number — MELISSA A SUTTON ANP

Table of content: MELISSA A SUTTON ANP (NPI 1528115755)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528115755 NPI number — MELISSA A SUTTON ANP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUTTON
Provider First Name:
MELISSA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ANP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOTTER
Provider Other First Name:
MELISSA
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
ANP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1528115755
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 19036
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELFAST
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04915-4085
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-381-7272
Provider Business Mailing Address Fax Number:
903-381-7269

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
709 HOLLYBROOK DRIVE
Provider Second Line Business Practice Location Address:
SUITE 2301
Provider Business Practice Location Address City Name:
LONGVIEW
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75605-2411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-757-4691
Provider Business Practice Location Address Fax Number:
903-757-4875
Provider Enumeration Date:
01/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP2300X , with the licence number:  657825 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: AP112666 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 165806403 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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