Healthcare Provider Details

I. General information

NPI: 1326081894
Provider Name (Legal Business Name): MARY LUEDTKE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 03/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W HOMER ST
MICHIGAN CITY IN
46360-4358
US

IV. Provider business mailing address

2000 GREEN RD SUITE 300
ANN ARBOR MI
48105-1598
US

V. Phone/Fax

Practice location:
  • Phone: 219-879-8511
  • Fax:
Mailing address:
  • Phone: 734-995-3764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71001174A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberARNP9278988
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: