Provider Demographics
NPI:1164617528
Name:LUTZ, STACY (LIC AC, LMP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:LUTZ
Suffix:
Gender:F
Credentials:LIC AC, LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 586
Mailing Address - Street 2:
Mailing Address - City:EASTSOUND
Mailing Address - State:WA
Mailing Address - Zip Code:98245-0586
Mailing Address - Country:US
Mailing Address - Phone:360-472-0288
Mailing Address - Fax:
Practice Address - Street 1:141 PRUNE ALLEY
Practice Address - Street 2:SUITE 109
Practice Address - City:EASTSOUND
Practice Address - State:WA
Practice Address - Zip Code:98245
Practice Address - Country:US
Practice Address - Phone:360-472-0288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA240171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist