Healthcare Provider Details

I. General information

NPI: 1720030406
Provider Name (Legal Business Name): GENE C HUTSELL NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 08/11/2020
Certification Date: 08/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 PUEBLO DR
LAKE HAVASU CITY AZ
86406-8918
US

IV. Provider business mailing address

PO BOX 813
LAKE HAVASU CITY AZ
86405-0813
US

V. Phone/Fax

Practice location:
  • Phone: 928-669-6669
  • Fax:
Mailing address:
  • Phone: 928-669-6669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP30004998
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN114639
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: