Provider Demographics
NPI:1750621199
Name:MONTIERTH, SUZANNAH MIA (OTR:, CLT)
Entity type:Individual
Prefix:
First Name:SUZANNAH
Middle Name:MIA
Last Name:MONTIERTH
Suffix:
Gender:F
Credentials:OTR:, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:269 S 230 E
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-5558
Mailing Address - Country:US
Mailing Address - Phone:801-722-9673
Mailing Address - Fax:
Practice Address - Street 1:269 S 230 E
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-5558
Practice Address - Country:US
Practice Address - Phone:801-722-9673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-21
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR282060314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility