Provider Demographics
NPI:1114954641
Name:LUTTRELL, DOUGLAS H (NP)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:H
Last Name:LUTTRELL
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 E WEISGARBER RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-2604
Mailing Address - Country:US
Mailing Address - Phone:865-584-4747
Mailing Address - Fax:
Practice Address - Street 1:930 E EMERALD AVE
Practice Address - Street 2:STE 813
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37917-4539
Practice Address - Country:US
Practice Address - Phone:865-546-9751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN92050363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3345173Medicaid
TN500028566OtherRR MEDICARE PIN
S53472Medicare UPIN
TN3345173Medicaid
TN3345173Medicare ID - Type UnspecifiedLEGACY PIN