Provider Demographics
NPI:1578848586
Name:OKUTORO-KETTER, SUSANNAH
Entity Type:Individual
Prefix:
First Name:SUSANNAH
Middle Name:
Last Name:OKUTORO-KETTER
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 1:205 WABASHA ST S
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55107-1805
Mailing Address - Country:US
Mailing Address - Phone:651-293-8191
Mailing Address - Fax:
Practice Address - Street 1:205 WABASHA ST S
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55107-1805
Practice Address - Country:US
Practice Address - Phone:651-293-8191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-21
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-219830-5367A00000X
NY001399176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife