Healthcare Provider Details

I. General information

NPI: 1871163964
Provider Name (Legal Business Name): TRINA SUTTLES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2021
Last Update Date: 06/30/2021
Certification Date: 06/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1332 SOUTHERN DR
STATESBORO GA
30460-1360
US

IV. Provider business mailing address

153 CRANAPPLE LN
MCDONOUGH GA
30253-7779
US

V. Phone/Fax

Practice location:
  • Phone: 912-478-4636
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: