Provider Demographics
NPI:1073030789
Name:LUTMAN, CARRIE ANN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:ANN
Last Name:LUTMAN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 RILEY LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ELLIS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:62241-1424
Mailing Address - Country:US
Mailing Address - Phone:618-304-9024
Mailing Address - Fax:
Practice Address - Street 1:818 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:IL
Practice Address - Zip Code:62286-1820
Practice Address - Country:US
Practice Address - Phone:618-443-2177
Practice Address - Fax:618-443-1380
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041344824363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily