Provider Demographics
NPI:1083389274
Name:SUTTON, NICOLE RITA
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RITA
Last Name:SUTTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5816 LEATHERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:NC
Mailing Address - Zip Code:28075-5015
Mailing Address - Country:US
Mailing Address - Phone:704-425-2465
Mailing Address - Fax:
Practice Address - Street 1:3800 SHAMROCK DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-3220
Practice Address - Country:US
Practice Address - Phone:704-532-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA7617225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant