Provider Demographics
NPI:1346484235
Name:NUTTLI, THERESA JEANNE
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:JEANNE
Last Name:NUTTLI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1978 INDUSTRIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70363-7055
Mailing Address - Country:US
Mailing Address - Phone:504-460-0270
Mailing Address - Fax:
Practice Address - Street 1:520 RIDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001-6126
Practice Address - Country:US
Practice Address - Phone:504-460-0270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-23
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.206812207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1883972Medicaid
LA1883972Medicaid