Provider Demographics
NPI:1164719969
Name:LUTJEN, DINA LYNN (CRNA)
Entity Type:Individual
Prefix:
First Name:DINA
Middle Name:LYNN
Last Name:LUTJEN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 NE LAMPLIGHTER LN
Mailing Address - Street 2:
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64014-1340
Mailing Address - Country:US
Mailing Address - Phone:816-582-9304
Mailing Address - Fax:
Practice Address - Street 1:1209 NW NORTH RIDGE DR
Practice Address - Street 2:SUITE B
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64015-6321
Practice Address - Country:US
Practice Address - Phone:816-988-8415
Practice Address - Fax:816-988-8395
Is Sole Proprietor?:No
Enumeration Date:2011-06-30
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011023085367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1164719969Medicaid
MOS55000035Medicare PIN