Provider Demographics
NPI:1790023737
Name:SUTTON, DIEDRA (LPN)
Entity Type:Individual
Prefix:
First Name:DIEDRA
Middle Name:
Last Name:SUTTON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8531 RIDGEWAY AVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-4195
Mailing Address - Country:US
Mailing Address - Phone:585-285-3091
Mailing Address - Fax:
Practice Address - Street 1:8531 RIDGEWAY AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-4195
Practice Address - Country:US
Practice Address - Phone:585-285-3091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-25
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK6787164W00000X
AK37513163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse