Healthcare Provider Details

I. General information

NPI: 1013545615
Provider Name (Legal Business Name): ANNELISE KUTZLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2020
Last Update Date: 07/07/2022
Certification Date: 07/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 8TH AVE
FORT WORTH TX
76104-4110
US

IV. Provider business mailing address

713 E ANDERSON ST
WEATHERFORD TX
76086-5705
US

V. Phone/Fax

Practice location:
  • Phone: 817-922-4534
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number1669472387
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: