Provider Demographics
NPI:1689868317
Name:TUTT, JACQUELINE ANN (LPN)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:ANN
Last Name:TUTT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOX 767
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:AZ
Mailing Address - Zip Code:85550
Mailing Address - Country:US
Mailing Address - Phone:928-475-2640
Mailing Address - Fax:
Practice Address - Street 1:SKILL CENTER RD.
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:AZ
Practice Address - Zip Code:85550
Practice Address - Country:US
Practice Address - Phone:928-475-2262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-06
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP024818164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse