Provider Demographics
NPI:1861461071
Name:LUTZ, KATHI A (RN, FNP)
Entity Type:Individual
Prefix:
First Name:KATHI
Middle Name:A
Last Name:LUTZ
Suffix:
Gender:F
Credentials:RN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 E BROADWAY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-8023
Mailing Address - Country:US
Mailing Address - Phone:573-256-7700
Mailing Address - Fax:573-256-3004
Practice Address - Street 1:1605 E BROADWAY STE 300
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8023
Practice Address - Country:US
Practice Address - Phone:573-256-7700
Practice Address - Fax:573-256-3003
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO093278363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO423927805Medicaid
MO423927805Medicaid
MOS77396Medicare UPIN