Provider Demographics
NPI:1649938085
Name:LUTE, CHARLENE (LMT)
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:LUTE
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 1:3861 ELDRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-2154
Mailing Address - Country:US
Mailing Address - Phone:361-443-0279
Mailing Address - Fax:
Practice Address - Street 1:1526 UNIVERSITY BLVD W # LOFT12
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-2006
Practice Address - Country:US
Practice Address - Phone:361-443-0278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-02
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL86692225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist