Healthcare Provider Details

I. General information

NPI: 1164299483
Provider Name (Legal Business Name): MATILDA LUTAJ FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2023
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10350 HALIGUS RD STE A
HUNTLEY IL
60142-9545
US

IV. Provider business mailing address

10350 HALIGUS RD STE A
HUNTLEY IL
60142-9545
US

V. Phone/Fax

Practice location:
  • Phone: 815-338-6600
  • Fax: 847-802-7162
Mailing address:
  • Phone: 815-338-6600
  • Fax: 847-802-7162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209028960
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.028960
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: