Provider Demographics
NPI:1255382883
Name:LUTY, CONNIE RUTH (ARNP)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:RUTH
Last Name:LUTY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:818 N EMPORIA ST
Mailing Address - Street 2:STE 200
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-3729
Mailing Address - Country:US
Mailing Address - Phone:316-263-0296
Mailing Address - Fax:316-263-9523
Practice Address - Street 1:818 N EMPORIA ST
Practice Address - Street 2:STE 200
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-3729
Practice Address - Country:US
Practice Address - Phone:316-263-0296
Practice Address - Fax:316-263-9523
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS44171363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSP68518Medicare UPIN
KS160863Medicare ID - Type Unspecified