Provider Demographics
NPI:1417407743
Name:LUTZ, LAUREN C (NP)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:C
Last Name:LUTZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:C
Other - Last Name:FULTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:645 S ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2353
Mailing Address - Country:US
Mailing Address - Phone:812-339-1691
Mailing Address - Fax:812-337-2438
Practice Address - Street 1:720 N MARR RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-6660
Practice Address - Country:US
Practice Address - Phone:812-314-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-11
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71006708A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health