Provider Demographics
NPI:1336517119
Name:SUTHERLAND, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:SUTHERLAND
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 1:1101 E STONE DR
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3384
Mailing Address - Country:US
Mailing Address - Phone:423-224-1110
Mailing Address - Fax:423-224-1130
Practice Address - Street 1:1101 E STONE DR
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3384
Practice Address - Country:US
Practice Address - Phone:423-224-1110
Practice Address - Fax:423-224-1130
Is Sole Proprietor?:No
Enumeration Date:2015-09-10
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20220363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily