Healthcare Provider Details

I. General information

NPI: 1427828177
Provider Name (Legal Business Name): DEIDRA K KUTZLI FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2024
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 S MAIN ST
BRYAN OH
43506-1755
US

IV. Provider business mailing address

329 N WEST STREET
LIMA OH
45801-4332
US

V. Phone/Fax

Practice location:
  • Phone: 567-239-4562
  • Fax: 419-225-8878
Mailing address:
  • Phone: 419-221-3072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.0035598
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: