Provider Demographics
NPI:1376746867
Name:DUTTON, TAMMIE (RN)
Entity Type:Individual
Prefix:
First Name:TAMMIE
Middle Name:
Last Name:DUTTON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 HAVASUPAI BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-3798
Mailing Address - Country:US
Mailing Address - Phone:928-505-6911
Mailing Address - Fax:928-505-6991
Practice Address - Street 1:695 THUNDERBOLT AVE
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86406-7103
Practice Address - Country:US
Practice Address - Phone:928-505-6911
Practice Address - Fax:928-505-6991
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN096150164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
566151Medicare UPIN