Provider Demographics
NPI:1871894857
Name:SUT-PRATHER, KATHLEEN
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:SUT-PRATHER
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 1:854 BACKLOOP RD
Mailing Address - Street 2:
Mailing Address - City:HAVANA
Mailing Address - State:FL
Mailing Address - Zip Code:32333-6117
Mailing Address - Country:US
Mailing Address - Phone:850-545-5528
Mailing Address - Fax:850-539-9539
Practice Address - Street 1:854 BACKLOOP RD
Practice Address - Street 2:
Practice Address - City:HAVANA
Practice Address - State:FL
Practice Address - Zip Code:32333-6117
Practice Address - Country:US
Practice Address - Phone:850-545-5528
Practice Address - Fax:850-539-9539
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-08
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL683132098172V00000X
FL683132096172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL683132098Medicaid
FL683132096Medicaid