Provider Demographics
NPI:1275729410
Name:SUTHERLAND, MARILYN S (NP)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:S
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 N MAIN ST
Mailing Address - Street 2:JDK BEHAVORIAL HEALTH CENTER
Mailing Address - City:PENN YAN
Mailing Address - State:NY
Mailing Address - Zip Code:14527-1069
Mailing Address - Country:US
Mailing Address - Phone:315-531-2400
Mailing Address - Fax:
Practice Address - Street 1:465 N MAIN ST
Practice Address - Street 2:JDK BEHAVORIAL HEALTH CENTER
Practice Address - City:PENN YAN
Practice Address - State:NY
Practice Address - Zip Code:14527-1069
Practice Address - Country:US
Practice Address - Phone:315-531-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-21
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF301378363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health