Provider Demographics
NPI:1881046167
Name:SUTAK, THERESA M (MSN, APRN, FNP-C)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:M
Last Name:SUTAK
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 NORTH MAIN STREET
Mailing Address - Street 2:SUITE 332
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45415
Mailing Address - Country:US
Mailing Address - Phone:937-832-7337
Mailing Address - Fax:937-832-4817
Practice Address - Street 1:1425 N FAIRFIELD RD STE 130
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45432-2673
Practice Address - Country:US
Practice Address - Phone:937-320-1950
Practice Address - Fax:937-320-9332
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3010369363L00000X
OHAPRN.CNP.020536363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK201490Medicare PIN