Basic Information
| Provider Information | |||||||||
| NPI: | 1073030789 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUTMAN | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4800 RILEY LAKE RD | ||||||||
| Address2: | |||||||||
| City: | ELLIS GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622411424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183049024 | ||||||||
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| Practice Location | |||||||||
| Address1: | 818 E BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | SPARTA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622861820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184432177 | ||||||||
| FaxNumber: | 6184431380 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2017 | ||||||||
| LastUpdateDate: | 02/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 041344824 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.