Provider Demographics
NPI:1396153540
Name:LUTTRELL, MACKENNA (LMP)
Entity type:Individual
Prefix:
First Name:MACKENNA
Middle Name:
Last Name:LUTTRELL
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:956 14TH ST
Mailing Address - Street 2:
Mailing Address - City:WASHOUGAL
Mailing Address - State:WA
Mailing Address - Zip Code:98671
Mailing Address - Country:US
Mailing Address - Phone:360-909-1173
Mailing Address - Fax:
Practice Address - Street 1:13025 NE FOURTH PLAIN BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98682
Practice Address - Country:US
Practice Address - Phone:360-718-8240
Practice Address - Fax:360-718-8241
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-31
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60486817174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist