Provider Demographics
NPI:1487837324
Name:LUTZY, TRACY INEZ
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:INEZ
Last Name:LUTZY
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 1:5276 ABBE DR
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13219-3002
Mailing Address - Country:US
Mailing Address - Phone:315-480-6509
Mailing Address - Fax:
Practice Address - Street 1:5276 ABBE DR
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13219-3002
Practice Address - Country:US
Practice Address - Phone:315-480-6509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-14
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY269522-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0276299Medicaid