Provider Demographics
NPI:1043533128
Name:SUTTON, KERI LYNN (NP)
Entity type:Individual
Prefix:
First Name:KERI
Middle Name:LYNN
Last Name:SUTTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1435 E BRADFORD PARKWAY SUITE 105
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-6519
Mailing Address - Country:US
Mailing Address - Phone:417-881-4994
Mailing Address - Fax:417-881-4998
Practice Address - Street 1:1730 E REPUBLIC RD STE K
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-6519
Practice Address - Country:US
Practice Address - Phone:417-881-4994
Practice Address - Fax:417-881-4998
Is Sole Proprietor?:No
Enumeration Date:2010-03-03
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010006173363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1730456013OtherNPI
MO1508157140OtherNPI
MA3415Medicare PIN
MOMA3416Medicare UPIN