Healthcare Provider Details

I. General information

NPI: 1821529629
Provider Name (Legal Business Name): LYNN MARIE KUTZ LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2017
Last Update Date: 03/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 LEDGEVIEW AVE
FOND DU LAC WI
54935-3642
US

IV. Provider business mailing address

224 LEDGEVIEW AVE
FOND DU LAC WI
54935-3642
US

V. Phone/Fax

Practice location:
  • Phone: 920-470-7488
  • Fax:
Mailing address:
  • Phone: 920-470-7488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number1599-146
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: