Provider Demographics
NPI:1780276766
Name:LUTZ, TAMARA N
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:N
Last Name:LUTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3977 MAYFAIR RD APT 204
Mailing Address - Street 2:
Mailing Address - City:UNIONTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44685-8110
Mailing Address - Country:US
Mailing Address - Phone:330-937-4259
Mailing Address - Fax:
Practice Address - Street 1:3445 S MAIN ST
Practice Address - Street 2:
Practice Address - City:COVENTRY TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:44319-3028
Practice Address - Country:US
Practice Address - Phone:330-644-4095
Practice Address - Fax:330-645-2031
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0002158175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist