Provider Demographics
NPI:1619517869
Name:SUDDUTH, CRISTEN N
Entity Type:Individual
Prefix:
First Name:CRISTEN
Middle Name:N
Last Name:SUDDUTH
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 1:374 SAVANNA ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39212-5257
Mailing Address - Country:US
Mailing Address - Phone:404-940-4442
Mailing Address - Fax:
Practice Address - Street 1:374 SAVANNA ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39212-5257
Practice Address - Country:US
Practice Address - Phone:404-940-4442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX120331225X00000X
CA20686225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist