Provider Demographics
NPI:1407885346
Name:KUTZ, SUSAN LYNN (CRNA)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:LYNN
Last Name:KUTZ
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 LAKE PINE RD
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-7476
Mailing Address - Country:US
Mailing Address - Phone:704-663-7928
Mailing Address - Fax:
Practice Address - Street 1:612 MOCKSVILLE AVE
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-2732
Practice Address - Country:US
Practice Address - Phone:704-210-5661
Practice Address - Fax:704-210-5660
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC32363367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8050224Medicaid
NC430044436OtherRR MEDICARE