MEDICARE: HEATHER LYNN SUTTLE

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	390200000X	Student in an Organized Health Care Education/Training Program
2	2255A2300X	Athletic Trainer
3	2255A2300X	Athletic Trainer	AT1761	KY

General Provider Information

NPI Number	:	1902336936
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER LYNN SUTTLE

Provider Business Mailing Address
First Line	:	2225 STONE CREEK LN
Second Line	:
City	:	TERRE HAUTE
State	:	IN
Zip	:	47802-5438
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6206 DESERT STORM AVE
Second Line	:
City	:	FORT CAMPBELL
State	:	KY
Zip	:	42223-5702
Country	:	US
Telephone Number	:	661-993-7102
Fax Number	:

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

Provider Enumeration Date	:	06/13/2017
Last Update Date	:	09/02/2022

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