Healthcare Provider Details

I. General information

NPI: 1023293990
Provider Name (Legal Business Name): COREY SUTTER FNP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2008
Last Update Date: 05/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2019 GALISTEO ST STE J-1
SANTA FE NM
87505-2143
US

IV. Provider business mailing address

2019 GALISTEO ST STE J-1
SANTA FE NM
87505-2143
US

V. Phone/Fax

Practice location:
  • Phone: 505-820-0446
  • Fax: 505-820-6142
Mailing address:
  • Phone: 505-820-0446
  • Fax: 505-820-6142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR29804
License Number StateNM

VIII. Authorized Official

Name: MS. COREY SUTTER
Title or Position: FNP
Credential: FNP
Phone: 505-820-0446