Provider Demographics
NPI:1326653403
Name:SUTHERLAND, WANDA S (INDEPENDENT PROVIDER)
Entity Type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:S
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:INDEPENDENT PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 ERIE CT
Mailing Address - Street 2:
Mailing Address - City:PORT CLINTON
Mailing Address - State:OH
Mailing Address - Zip Code:43452-1612
Mailing Address - Country:US
Mailing Address - Phone:706-264-6282
Mailing Address - Fax:
Practice Address - Street 1:413 ERIE CT
Practice Address - Street 2:
Practice Address - City:PORT CLINTON
Practice Address - State:OH
Practice Address - Zip Code:43452-1612
Practice Address - Country:US
Practice Address - Phone:706-264-6282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6202153376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker