Provider Demographics
NPI:1972707180
Name:LUTZ, BRIDGET ANN (BA, RN)
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:ANN
Last Name:LUTZ
Suffix:
Gender:F
Credentials:BA, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 LAKEVIEW DR
Mailing Address - Street 2:APT #3
Mailing Address - City:HARTLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53029-1626
Mailing Address - Country:US
Mailing Address - Phone:608-561-1677
Mailing Address - Fax:
Practice Address - Street 1:260 LAKEVIEW DR
Practice Address - Street 2:APT #3
Practice Address - City:HARTLAND
Practice Address - State:WI
Practice Address - Zip Code:53029-1626
Practice Address - Country:US
Practice Address - Phone:608-561-1677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
WI169557163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No171M00000XOther Service ProvidersCase Manager/Care Coordinator