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* 1. Clinician's Full Name and degree (NP, PA, AUD):

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* 2. Clinician's NPI

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* 3. CA License #:

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* 4. Clinician's DOB:

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* 5. Preferred Pronouns: her/she, him/he, they/them:

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* 6. Clinician’s Mobile Phone Number:

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* 7. Clinician’s Preferred Email:

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* 8. Practice Name/Group Name:

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* 9. Clinic Office Locations:

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* 10. Primary Supervising Physician:

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* 11. OFFICE MANAGER/CREDENTIALING CONTACT

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* 12. VACCINE ATTESTATION
Does clinician support the CDC recommended vaccinations:

  Yes No
For themselves?
For their patients?
*Please ensure the emails listed above are accurate. Credentialing applications are sent via email.
Please submit a copy of the clinician's curriculum vitae (CV) to: Danielle Conner at danielle.conner@sutterhealth.org or fax to 916-503-3751.
Credentialing Policy: The submission of this form is NOT authorization to render medical care to contracted health plan enrollees. Sutter Independent Physicians (SIP) & Sutter Valley Medical Foundation (SVMF) requires all licensed clinicians to be credentialing approved prior to rendering medical care to contracted health plan enrollees.
Questions? Contact Danielle Conner at danielle.conner@sutterhealth.org or 916-887-4911.

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