Provider Demographics
NPI:1609219930
Name:LUTTRELL, TAUSHA
Entity Type:Individual
Prefix:
First Name:TAUSHA
Middle Name:
Last Name:LUTTRELL
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 1:784 N PENDLETON AVE
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:IN
Mailing Address - Zip Code:46064-8977
Mailing Address - Country:US
Mailing Address - Phone:317-709-4559
Mailing Address - Fax:
Practice Address - Street 1:8609 E 116TH ST
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-1560
Practice Address - Country:US
Practice Address - Phone:317-709-4559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-17
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT20903175174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist