Provider Demographics
NPI:1043334477
Name:SUTER, SALLY (FNP ND)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:
Last Name:SUTER
Suffix:
Gender:F
Credentials:FNP ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2218 BRENEMAN ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702
Mailing Address - Country:US
Mailing Address - Phone:208-336-6681
Mailing Address - Fax:
Practice Address - Street 1:704 S LATAH
Practice Address - Street 2:THE FRIENDSHIP CLINIC
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706
Practice Address - Country:US
Practice Address - Phone:208-429-6678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP492A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
S37015Medicare UPIN
S37015Medicare ID - Type Unspecified