Provider Demographics
NPI:1184483604
Name:SUTTER, REALYN
Entity type:Individual
Prefix:
First Name:REALYN
Middle Name:
Last Name:SUTTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16502 BAIRD CIR
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-6710
Mailing Address - Country:US
Mailing Address - Phone:907-696-0800
Mailing Address - Fax:
Practice Address - Street 1:16502 BAIRD CIR
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-6710
Practice Address - Country:US
Practice Address - Phone:907-696-0800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101589310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility