=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407676935
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA SUTLIFF RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2024
-----------------------------------------------------
Last Update Date | 10/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 625 STEELE LN
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95403-3127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-576-0818
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2134 SMOKETREE CT
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95403-7933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-479-4070
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | RN95201028
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------