Healthcare Provider Details

I. General information

NPI: 1194629493
Provider Name (Legal Business Name): ANNA GRACE SUDDERTH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

947 S BROAD ST
THOMASVILLE GA
31792-6161
US

IV. Provider business mailing address

3335 RHEA RD APT 104
TALLAHASSEE FL
32312-0964
US

V. Phone/Fax

Practice location:
  • Phone: 229-551-1883
  • Fax:
Mailing address:
  • Phone: 229-894-9667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: