Provider Demographics
NPI:1679228431
Name:LUTZ, PENELOPE ELIZABETH (APRN, A-GNP-C)
Entity Type:Individual
Prefix:
First Name:PENELOPE
Middle Name:ELIZABETH
Last Name:LUTZ
Suffix:
Gender:F
Credentials:APRN, A-GNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2155 DALKE RIDGE DR NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-4830
Mailing Address - Country:US
Mailing Address - Phone:503-383-8793
Mailing Address - Fax:
Practice Address - Street 1:610 HAWTHORNE AVE SE STE 250
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-5436
Practice Address - Country:US
Practice Address - Phone:503-559-3312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-19
Last Update Date:2022-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202201833NP-PP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health