Provider Demographics
NPI:1295421675
Name:SUTTON, STACY
Entity type:Individual
Prefix:MR
First Name:STACY
Middle Name:
Last Name:SUTTON
Suffix:
Gender:M
Credentials:
Other - Prefix:MRS
Other - First Name:LATISHA
Other - Middle Name:
Other - Last Name:SUTTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:529 STREAMWATER DR
Mailing Address - Street 2:
Mailing Address - City:BLACKLICK
Mailing Address - State:OH
Mailing Address - Zip Code:43004-8138
Mailing Address - Country:US
Mailing Address - Phone:380-250-2690
Mailing Address - Fax:
Practice Address - Street 1:529 STREAMWATER DR
Practice Address - Street 2:
Practice Address - City:BLACKLICK
Practice Address - State:OH
Practice Address - Zip Code:43004-8138
Practice Address - Country:US
Practice Address - Phone:380-250-2690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRR064991172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver