MEDICARE: JILL LUTKEVICH RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	R1396315	MN

General Provider Information

NPI Number	:	1639438773
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JILL LUTKEVICH RN

Provider Business Mailing Address
First Line	:	4961 RICE LAKE RD
Second Line	:	SUITE 105
City	:	DULUTH
State	:	MN
Zip	:	55803-8438
Country	:	US
Telephone Number	:	218-727-0296
Fax Number	:	218-727-4135

Provider Business Practice Location Address
First Line	:	4961 RICE LAKE RD
Second Line	:	SUITE 105
City	:	DULUTH
State	:	MN
Zip	:	55803-8438
Country	:	US
Telephone Number	:	218-727-0296
Fax Number	:	218-727-4135

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/10/2012
Last Update Date	:	05/10/2012

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