Healthcare Provider Details

I. General information

NPI: 1043651128
Provider Name (Legal Business Name): KATIE LYNNE SUTTER OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2013
Last Update Date: 07/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6101 NEWPORT RD STE A
PORTAGE MI
49002-9237
US

IV. Provider business mailing address

6101 NEWPORT RD STE A
PORTAGE MI
49002-9237
US

V. Phone/Fax

Practice location:
  • Phone: 269-382-6500
  • Fax: 269-382-2286
Mailing address:
  • Phone: 269-382-6500
  • Fax: 269-382-2286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number4901004789
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: