Provider Demographics
NPI:1093255580
Name:FERNANDO, SUTHA M
Entity Type:Individual
Prefix:
First Name:SUTHA
Middle Name:M
Last Name:FERNANDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NA
Other - Middle Name:NA
Other - Last Name:NA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SUTHA MS RN FNP-C
Mailing Address - Street 1:2760 E TRINITY MILLS RD STE 115
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75006-2194
Mailing Address - Country:US
Mailing Address - Phone:214-949-1209
Mailing Address - Fax:214-826-2196
Practice Address - Street 1:2760 E TRINITY MILLS RD STE 115
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75006-2194
Practice Address - Country:US
Practice Address - Phone:214-949-1209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-02
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP133138363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX$$$$$$$$$Medicaid
TX199822879Medicare PIN