Provider Demographics
NPI:1639438773
Name:LUTKEVICH, JILL (RN)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:LUTKEVICH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4961 RICE LAKE RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55803-8438
Mailing Address - Country:US
Mailing Address - Phone:218-727-0296
Mailing Address - Fax:218-727-4135
Practice Address - Street 1:4961 RICE LAKE RD
Practice Address - Street 2:SUITE 105
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55803-8438
Practice Address - Country:US
Practice Address - Phone:218-727-0296
Practice Address - Fax:218-727-4135
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-10
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1396315163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse