Provider Demographics
NPI:1255631602
Name:DUTKIEWICZ, LISA (LMT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:DUTKIEWICZ
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24100 SW BEAVER DR
Mailing Address - Street 2:
Mailing Address - City:DUNNELLON
Mailing Address - State:FL
Mailing Address - Zip Code:34431-3108
Mailing Address - Country:US
Mailing Address - Phone:352-274-7125
Mailing Address - Fax:
Practice Address - Street 1:20170 E PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:DUNNELLON
Practice Address - State:FL
Practice Address - Zip Code:34432-6032
Practice Address - Country:US
Practice Address - Phone:352-274-7125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-01
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA36477174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC1853OtherBCBS