Provider Demographics
NPI:1417630625
Name:KOUTECKY, LORI KAY
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:KAY
Last Name:KOUTECKY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:NE
Mailing Address - Zip Code:68347-5083
Mailing Address - Country:US
Mailing Address - Phone:402-781-2210
Mailing Address - Fax:
Practice Address - Street 1:600 S 1ST ST
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:NE
Practice Address - Zip Code:68347-5083
Practice Address - Country:US
Practice Address - Phone:402-781-2210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant