Provider Demographics
NPI:1598883134
Name:LYTTLE, SHARON DIANE (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:SHARON
Middle Name:DIANE
Last Name:LYTTLE
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 BETH DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-2042
Mailing Address - Country:US
Mailing Address - Phone:615-758-0772
Mailing Address - Fax:
Practice Address - Street 1:3580 N MOUNT JULIET RD
Practice Address - Street 2:
Practice Address - City:MOUNT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-3061
Practice Address - Country:US
Practice Address - Phone:615-758-4888
Practice Address - Fax:615-758-6188
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1744000000X174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3126907Medicaid
TN4102606OtherBLUE CROSS BLUE SHEILD