Provider Demographics
NPI:1962053819
Name:SUTHERLAND, NICOLE JANINE (MED, ATC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:JANINE
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:MED, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1830 VIA PACIFICA
Mailing Address - Street 2:
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95003-5870
Mailing Address - Country:US
Mailing Address - Phone:831-706-5297
Mailing Address - Fax:
Practice Address - Street 1:2400 E LAKE AVE
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-1427
Practice Address - Country:US
Practice Address - Phone:831-706-5297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer