Provider Demographics
NPI:1275123135
Name:SUTTON, KENNEATRIA LATANYA
Entity Type:Individual
Prefix:
First Name:KENNEATRIA
Middle Name:LATANYA
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 1:44175 W 12 MILE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-1982
Mailing Address - Country:US
Mailing Address - Phone:734-320-7201
Mailing Address - Fax:
Practice Address - Street 1:44175 W 12 MILE RD STE 1
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-1982
Practice Address - Country:US
Practice Address - Phone:734-320-7201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-24
Last Update Date:2021-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI27011453871744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty