Basic Information
| Provider Information | |||||||||
| NPI: | 1033162409 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KUTZBACH | ||||||||
| FirstName: | LINDA | ||||||||
| MiddleName: | FAY | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KING | ||||||||
| OtherFirstName: | LINDA | ||||||||
| OtherMiddleName: | FAY | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 16111 PLUMMER ST | ||||||||
| Address2: | BLDG 99 | ||||||||
| City: | NORTH HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913432036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188917711 | ||||||||
| FaxNumber: | 8188955817 | ||||||||
| Practice Location | |||||||||
| Address1: | 16111 PLUMMER ST | ||||||||
| Address2: | BLDG 99 | ||||||||
| City: | NORTH HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913432036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188917711 | ||||||||
| FaxNumber: | 8188955817 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | X | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 190049 | CA | X | Nursing Service Providers | Registered Nurse | 363L00000X | 10245 | CA | X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 190049 | 01 | CA | RN LICENSE | OTHER |