Provider Demographics
NPI:1265446884
Name:FLETTRICH, DEBORAH D (RN/CRNA)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:D
Last Name:FLETTRICH
Suffix:
Gender:F
Credentials:RN/CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:262 DANNY THOMAS PL
Mailing Address - Street 2:MS 515
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38105-3678
Mailing Address - Country:US
Mailing Address - Phone:901-595-3006
Mailing Address - Fax:901-595-3842
Practice Address - Street 1:262 DANNY THOMAS PL
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105-3678
Practice Address - Country:US
Practice Address - Phone:901-595-3006
Practice Address - Fax:901-595-3842
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN73516163W00000X
TN11657367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR159246001Medicaid
LA1555738Medicaid
IN200803610AMedicaid
TN5440665Medicaid
OK200071170AMedicaid
MO917570509Medicaid
MS09631271Medicaid