Basic Information
| Provider Information | |||||||||
| NPI: | 1356961932 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUDDUTH | ||||||||
| FirstName: | LILLIAN | ||||||||
| MiddleName: | GRACE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | CRNP | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 635 W COLLEGE ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356305313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567643431 | ||||||||
| FaxNumber: | 2567652036 | ||||||||
| Practice Location | |||||||||
| Address1: | 635 W COLLEGE ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356305313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567687453 | ||||||||
| FaxNumber: | 2567652036 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2020 | ||||||||
| LastUpdateDate: | 08/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 175980 | AL | N | Nursing Service Providers | Registered Nurse | 363LP0808X | 1-175980 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.