Provider Demographics
NPI:1174917785
Name:SUDDUTH, STEFANIE ANN (MM)
Entity type:Individual
Prefix:MRS
First Name:STEFANIE
Middle Name:ANN
Last Name:SUDDUTH
Suffix:
Gender:F
Credentials:MM
Other - Prefix:MS
Other - First Name:STEFANIE
Other - Middle Name:ANN
Other - Last Name:NELMS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1031 ARDSLEY RD
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12308-3011
Mailing Address - Country:US
Mailing Address - Phone:770-778-1644
Mailing Address - Fax:
Practice Address - Street 1:597 3RD AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12182-2509
Practice Address - Country:US
Practice Address - Phone:518-233-0544
Practice Address - Fax:518-233-0703
Is Sole Proprietor?:No
Enumeration Date:2015-03-20
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2560414174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist