Healthcare Provider Details

I. General information

NPI: 1144993882
Provider Name (Legal Business Name): NINA SHANNON SUTHERLAND NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NINA SHANNON JORDAN

II. Dates (important events)

Enumeration Date: 07/28/2021
Last Update Date: 07/28/2021
Certification Date: 07/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3970 DEPUTY BILL CANTRELL MEM
CUMMING GA
30040-3069
US

IV. Provider business mailing address

1750 WALKING HORSE TRL
CUMMING GA
30041-8389
US

V. Phone/Fax

Practice location:
  • Phone: 678-513-2273
  • Fax:
Mailing address:
  • Phone: 678-283-8452
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN145366
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: