Provider Demographics
NPI:1801394473
Name:MCCUTCHAN, MARY SUZANNE (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SUZANNE
Last Name:MCCUTCHAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:SUZANNE
Other - Last Name:FREEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:FRUITA
Mailing Address - State:CO
Mailing Address - Zip Code:81521-0130
Mailing Address - Country:US
Mailing Address - Phone:970-858-2186
Mailing Address - Fax:970-858-2208
Practice Address - Street 1:551 KOKOPELLI BLVD UNIT H
Practice Address - Street 2:
Practice Address - City:FRUITA
Practice Address - State:CO
Practice Address - Zip Code:81521-6305
Practice Address - Country:US
Practice Address - Phone:970-858-2530
Practice Address - Fax:970-858-1196
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0993306-NP363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health