Provider Demographics
NPI:1740493030
Name:TETRAULT, DEBRA DENISE
Entity type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:DENISE
Last Name:TETRAULT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:
Other - Last Name:LUCCHESI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8340 CEREUS CT
Mailing Address - Street 2:
Mailing Address - City:ANTELOPE
Mailing Address - State:CA
Mailing Address - Zip Code:95843
Mailing Address - Country:US
Mailing Address - Phone:916-723-2797
Mailing Address - Fax:
Practice Address - Street 1:3124 WIESE WAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95833
Practice Address - Country:US
Practice Address - Phone:916-922-8023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN114498164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5927935OtherPIN
CA012840OtherEPS
RVN001380Medicare UPIN