Provider Demographics
NPI:1376019547
Name:SUTHERLAND, PATRICIA
Entity Type:Individual
Prefix:
First Name:PATRICIA
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 1:3636 N 3600 E
Mailing Address - Street 2:
Mailing Address - City:KIMBERLY
Mailing Address - State:ID
Mailing Address - Zip Code:83341-5321
Mailing Address - Country:US
Mailing Address - Phone:208-490-0203
Mailing Address - Fax:
Practice Address - Street 1:622 CENTER ST W
Practice Address - Street 2:
Practice Address - City:KIMBERLY
Practice Address - State:ID
Practice Address - Zip Code:83341-1720
Practice Address - Country:US
Practice Address - Phone:208-490-0203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMID-91176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife