Provider Demographics
NPI:1902692049
Name:NUTTER, SHAWN DONNELL II
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:DONNELL
Last Name:NUTTER
Suffix:II
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 W BROADWAY STE 4
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-2236
Mailing Address - Country:US
Mailing Address - Phone:502-965-6539
Mailing Address - Fax:
Practice Address - Street 1:801 W BROADWAY STE 4
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-2236
Practice Address - Country:US
Practice Address - Phone:502-965-6539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-16
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility