Provider Demographics
NPI:1104134170
Name:MCNUTT, LENNIS DARRIN (SFIDC)
Entity type:Individual
Prefix:
First Name:LENNIS
Middle Name:DARRIN
Last Name:MCNUTT
Suffix:
Gender:M
Credentials:SFIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USS BENFOLD DDG 65
Mailing Address - Street 2:MEDICAL DEPARTMENT
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96661-1283
Mailing Address - Country:US
Mailing Address - Phone:619-556-3937
Mailing Address - Fax:
Practice Address - Street 1:USS BENFOLD DDG 65
Practice Address - Street 2:MEDICAL DEPARTMENT
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96661-1283
Practice Address - Country:US
Practice Address - Phone:619-556-3937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-23
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000003625OtherACTIVE DUTY NAVY