Provider Demographics
NPI:1639826852
Name:LUTZ, KRISTIN E
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:E
Last Name:LUTZ
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 1:429 MAPLE LEAF DR
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:MD
Mailing Address - Zip Code:21037-3207
Mailing Address - Country:US
Mailing Address - Phone:407-432-7390
Mailing Address - Fax:
Practice Address - Street 1:116 DEFENSE HWY STE 400
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7050
Practice Address - Country:US
Practice Address - Phone:410-897-9841
Practice Address - Fax:410-897-9852
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-08
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC004201363L00000X, 363LF0000X
VA0024183900363LF0000X
ALAC004201363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner