Provider Demographics
NPI:1235953613
Name:SUTPHIN, GLENN CARL (RN)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:CARL
Last Name:SUTPHIN
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 UNION DR
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-8822
Mailing Address - Country:US
Mailing Address - Phone:304-921-0275
Mailing Address - Fax:
Practice Address - Street 1:122 12TH ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2312
Practice Address - Country:US
Practice Address - Phone:304-487-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-12
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV81976163WF0300X
WV121399363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WF0300XNursing Service ProvidersRegistered NurseFlight