Healthcare Provider Details

I. General information

NPI: 1275162794
Provider Name (Legal Business Name): LISA ANNE KUTRIP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 04/06/2020
Certification Date: 04/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 N FLAMINGO RD
PEMBROKE PINES FL
33028-1014
US

IV. Provider business mailing address

1375 NW 159TH LN
PEMBROKE PINES FL
33028-1631
US

V. Phone/Fax

Practice location:
  • Phone: 954-844-9872
  • Fax:
Mailing address:
  • Phone: 305-632-2856
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number19241
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: