Provider Demographics
NPI:1023563707
Name:SUTHERLAND, DEANDRA RENEE
Entity Type:Individual
Prefix:
First Name:DEANDRA
Middle Name:RENEE
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:DEANDRA
Other - Middle Name:RENEE
Other - Last Name:HINDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:861 WESLEY ST
Mailing Address - Street 2:
Mailing Address - City:NORTH BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-1433
Mailing Address - Country:US
Mailing Address - Phone:718-807-8479
Mailing Address - Fax:
Practice Address - Street 1:861 WESLEY ST
Practice Address - Street 2:
Practice Address - City:NORTH BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-1433
Practice Address - Country:US
Practice Address - Phone:718-807-8479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-23
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY339860363LF0000X
NY604519163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse