Provider Demographics
NPI:1447627708
Name:GUTLOVE, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:GUTLOVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6046 WHIPPLE AVE NW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-7616
Mailing Address - Country:US
Mailing Address - Phone:330-433-1771
Mailing Address - Fax:330-493-9046
Practice Address - Street 1:100 LILLIAN GISH BLVD SW
Practice Address - Street 2:STE 201
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44647-6500
Practice Address - Country:US
Practice Address - Phone:330-809-0460
Practice Address - Fax:330-809-0560
Is Sole Proprietor?:No
Enumeration Date:2015-08-21
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA17988363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH379460Medicare PIN