Provider Demographics
NPI:1134424781
Name:SUDDUTH, TINA MARIE (REGISTERED NURSE)
Entity type:Individual
Prefix:MS
First Name:TINA
Middle Name:MARIE
Last Name:SUDDUTH
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14191 YALE ST
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92344-8290
Mailing Address - Country:US
Mailing Address - Phone:909-855-1545
Mailing Address - Fax:
Practice Address - Street 1:14191 YALE ST
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92344-8290
Practice Address - Country:US
Practice Address - Phone:909-855-1545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-12
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA396021163WN0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WN0003XNursing Service ProvidersRegistered NurseNeonatal, Low-Risk