Basic Information
| Provider Information | |||||||||
| NPI: | 1396743258 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUTTON-DAVIS | ||||||||
| FirstName: | LESA | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 638706 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452638706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708277558 | ||||||||
| FaxNumber: | 2708277530 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 N ELM ST STE 1B | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424202385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708448144 | ||||||||
| FaxNumber: | 2708448145 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2005 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 36607 | KY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 000000910700 | 01 | KY | ANTHEM - NCMA | OTHER | 170480 | 01 | KY | SIHO-NCMA | OTHER | 50086973 | 01 | KY | PASSPORT - NCMA FAIRDALE | OTHER | 50086969 | 01 | KY | PASSPORT - NCMA BRECKENRIDGE | OTHER | 64027493 | 05 | KY | MEDICAID |