Provider Demographics
NPI:1124235775
Name:SUTTON, MARY MCCLELLAN (LPN, CST,CFA,,SA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:MCCLELLAN
Last Name:SUTTON
Suffix:
Gender:F
Credentials:LPN, CST,CFA,,SA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1297 WALNUT GROVE LN
Mailing Address - Street 2:
Mailing Address - City:SNOW CAMP
Mailing Address - State:NC
Mailing Address - Zip Code:27349-9655
Mailing Address - Country:US
Mailing Address - Phone:336-376-3113
Mailing Address - Fax:336-376-1876
Practice Address - Street 1:1297 WALNUT GROVE LN
Practice Address - Street 2:
Practice Address - City:SNOW CAMP
Practice Address - State:NC
Practice Address - Zip Code:27349-9655
Practice Address - Country:US
Practice Address - Phone:336-376-3113
Practice Address - Fax:336-376-1876
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00F267247200000X
NC027608364SM0705X
TXSA00147364SM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Not Answered364SM0705XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistMedical-Surgical