Provider Demographics
NPI:1598067316
Name:LUTZ, LUCILLE FRANCES (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:LUCILLE
Middle Name:FRANCES
Last Name:LUTZ
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 52
Mailing Address - Street 2:48855 59 1/2 STREET
Mailing Address - City:HARTFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49057
Mailing Address - Country:US
Mailing Address - Phone:269-637-0388
Mailing Address - Fax:
Practice Address - Street 1:601 JOHN ST
Practice Address - Street 2:BOX 74
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5341
Practice Address - Country:US
Practice Address - Phone:269-341-7339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-30
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704228927363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1598067316Medicaid
MI1003822412OtherBCBSM - BRONSON METHODIST HOSPITAL
MI1003822412OtherBCBSM - BMH
MI1003822412OtherBCBSM - BMH