Provider Demographics
NPI:1154902773
Name:SUTHERLAND, MARIA R (FNP)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:R
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:R
Other - Last Name:SCHULT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:411 COVERED BRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-6111
Mailing Address - Country:US
Mailing Address - Phone:618-420-2186
Mailing Address - Fax:
Practice Address - Street 1:411 COVERED BRIDGE LN
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62221-6111
Practice Address - Country:US
Practice Address - Phone:618-420-2186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-15
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021010429363LF0000X
IL209022986363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily