Provider Demographics
NPI:1811213853
Name:LUTKEN, ANN ELIZABETH (CFNP)
Entity Type:Individual
Prefix:MRS
First Name:ANN
Middle Name:ELIZABETH
Last Name:LUTKEN
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9025 DRY GROVE RD
Mailing Address - Street 2:
Mailing Address - City:RAYMOND
Mailing Address - State:MS
Mailing Address - Zip Code:39154-9713
Mailing Address - Country:US
Mailing Address - Phone:601-214-5367
Mailing Address - Fax:
Practice Address - Street 1:971 LAKELAND DR STE 1250
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4609
Practice Address - Country:US
Practice Address - Phone:601-200-5955
Practice Address - Fax:601-200-5943
Is Sole Proprietor?:No
Enumeration Date:2010-04-15
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR875444163WE0003X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP01668935OtherRAILROAD MEDICARE
MS09702355Medicaid
MS09702355Medicaid