Provider Demographics
NPI:1043651128
Name:SUTTER, KATIE LYNNE (OD)
Entity Type:Individual
Prefix:DR
First Name:KATIE
Middle Name:LYNNE
Last Name:SUTTER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6101 NEWPORT RD STE A
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-9237
Mailing Address - Country:US
Mailing Address - Phone:269-382-6500
Mailing Address - Fax:269-382-2286
Practice Address - Street 1:6101 NEWPORT RD STE A
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-9237
Practice Address - Country:US
Practice Address - Phone:269-382-6500
Practice Address - Fax:269-382-2286
Is Sole Proprietor?:No
Enumeration Date:2013-07-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004789152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4901004789OtherLICENSE NUMBER