Provider Demographics
NPI:1962023341
Name:SUTTEN, KAITLIN NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:NICOLE
Last Name:SUTTEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KAITLIN
Other - Middle Name:NICOLE
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16033 VANOWEN ST APT 104
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-4868
Mailing Address - Country:US
Mailing Address - Phone:513-767-3910
Mailing Address - Fax:
Practice Address - Street 1:16033 VANOWEN ST APT 104
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-4868
Practice Address - Country:US
Practice Address - Phone:513-767-3910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-27
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA58117363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant