Provider Demographics
NPI:1902459662
Name:SUTTON, MINDY GRAY (APRN)
Entity Type:Individual
Prefix:MRS
First Name:MINDY
Middle Name:GRAY
Last Name:SUTTON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MINDY
Other - Middle Name:LEE
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:210 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-3737
Mailing Address - Country:US
Mailing Address - Phone:850-306-3433
Mailing Address - Fax:877-413-5104
Practice Address - Street 1:210 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-3737
Practice Address - Country:US
Practice Address - Phone:850-226-6801
Practice Address - Fax:877-413-5104
Is Sole Proprietor?:No
Enumeration Date:2019-07-22
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11002601363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105993400Medicaid
AL261330Medicaid