Provider Demographics
NPI:1083391700
Name:LUTTERMAN, MIRANDA K (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:K
Last Name:LUTTERMAN
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1509 ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:ANOKA
Mailing Address - State:MN
Mailing Address - Zip Code:55303-1365
Mailing Address - Country:US
Mailing Address - Phone:218-850-0071
Mailing Address - Fax:
Practice Address - Street 1:11660 ROUND LAKE BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2638
Practice Address - Country:US
Practice Address - Phone:763-767-3350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-04
Last Update Date:2023-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10413363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health