Healthcare Provider Details

I. General information

NPI: 1497287767
Provider Name (Legal Business Name): MARY FAULKNER LUTTRELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 MEADOW VIEW RD
BRISTOL TN
37620-1661
US

IV. Provider business mailing address

300 TATE RD
BLUFF CITY TN
37618-3341
US

V. Phone/Fax

Practice location:
  • Phone: 423-797-4555
  • Fax:
Mailing address:
  • Phone: 615-804-2082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT-VA-131
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5773
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: