Provider Demographics
NPI:1275110157
Name:SUTHERLIN, STACEY LEE (LPN)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LEE
Last Name:SUTHERLIN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:LEE
Other - Last Name:DARR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:354 TYEE ST
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7657
Mailing Address - Country:US
Mailing Address - Phone:907-714-5870
Mailing Address - Fax:
Practice Address - Street 1:354 TYEE ST
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7657
Practice Address - Country:US
Practice Address - Phone:907-714-5870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-26
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK147817164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse