Basic Information
| Provider Information | |||||||||
| NPI: | 1689795536 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MUTISO | ||||||||
| FirstName: | LORA | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1306 VERSAILLES RD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405041796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592592635 | ||||||||
| FaxNumber: | 8592547874 | ||||||||
| Practice Location | |||||||||
| Address1: | 1306 VERSAILLES RD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405041796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592592635 | ||||||||
| FaxNumber: | 8592547874 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2007 | ||||||||
| LastUpdateDate: | 04/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4380P | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0808X | 3004380 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 7100384290 | 05 | KY | MEDICAID |