Provider Demographics
NPI:1982272985
Name:LUTZ, JENNIFER COLLEEN (RN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:COLLEEN
Last Name:LUTZ
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:COLLEEN
Other - Last Name:HANNA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:332 ESHER CT
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-3325
Mailing Address - Country:US
Mailing Address - Phone:540-446-4327
Mailing Address - Fax:
Practice Address - Street 1:332 ESHER CT
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-3325
Practice Address - Country:US
Practice Address - Phone:540-446-4327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC108447163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse