MEDICARE: MS. REGINA RICHELLE SUDDUTH CRNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	1-139228	AL
2	363LA2100X	Acute Care Nurse Practitioner	1-139228	AL

General Provider Information

NPI Number	:	1265175186
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. REGINA RICHELLE SUDDUTH CRNP

Provider Business Mailing Address
First Line	:	235 WALKER DR
Second Line	:
City	:	LINEVILLE
State	:	AL
Zip	:	36266-6719
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	315 W FORT WILLIAMS ST
Second Line	:
City	:	SYLACAUGA
State	:	AL
Zip	:	35150-2433
Country	:	US
Telephone Number	:	256-249-6995
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/19/2022
Last Update Date	:	06/06/2024

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