Healthcare Provider Details

I. General information

NPI: 1215205620
Provider Name (Legal Business Name): DEBRA A SUKUP RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2011
Last Update Date: 12/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4750 WESLEY AVE
CINCINNATI OH
45212-2244
US

IV. Provider business mailing address

4750 WESLEY AVE
CINCINNATI OH
45212-2244
US

V. Phone/Fax

Practice location:
  • Phone: 513-531-5110
  • Fax: 513-531-1327
Mailing address:
  • Phone: 513-531-5110
  • Fax: 513-531-1327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN 140448
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: