Provider Demographics
NPI:1811380033
Name:LUTZEN, KELLY S (BS)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:S
Last Name:LUTZEN
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:S
Other - Last Name:STEELE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:202 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1507
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:345 W WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-2996
Practice Address - Country:US
Practice Address - Phone:608-417-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-12
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2247-029133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2247-029OtherCERTIFIED DIETITIAN