MEDICARE: MARY MCCLELLAN SUTTON LPN, CST,CFA,,SA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	247200000X	Other Technician	00F267	CO
2	364SM0705X	Medical-Surgical Clinical Nurse Specialist	027608	NC
3	364SM0705X	Medical-Surgical Clinical Nurse Specialist	SA00147	TX

General Provider Information

NPI Number	:	1124235775
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY MCCLELLAN SUTTON LPN, CST,CFA,,SA

Provider Business Mailing Address
First Line	:	1297 WALNUT GROVE LN
Second Line	:
City	:	SNOW CAMP
State	:	NC
Zip	:	27349-9655
Country	:	US
Telephone Number	:	336-376-3113
Fax Number	:	336-376-1876

Provider Business Practice Location Address
First Line	:	1297 WALNUT GROVE LN
Second Line	:
City	:	SNOW CAMP
State	:	NC
Zip	:	27349-9655
Country	:	US
Telephone Number	:	336-376-3113
Fax Number	:	336-376-1876

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	09/11/2025

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