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General NPI Number Information
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NPI Number | 1740266501
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Entity Type | Individual
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Provider Name | SHANNON RENAE SUTHERLAND D.O.
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Gender | Female
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Dates
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Enumeration Date | 12/22/2005
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Last Update Date | 01/18/2011
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Provider Practice Location Address
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Address Line | 1103 VILLAGE SQUARE DR SUITE 101
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City | PERRYSBURG
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State | OH
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Zip | 43551-1783
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Country | US
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Telephone | 419-872-3219
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Fax | 419-872-3208
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Provider Business Mailing Address
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Address Line | 5901 MONCLOVA RD
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City | MAUMEE
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State | OH
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Zip | 43537
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Country | US
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Telephone | 419-872-3201
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Fax | 419-872-3208
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | BL9255058
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | 34.008522
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License Number State | OH
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