Provider Demographics
NPI:1265114680
Name:LUTFY, MAHBOOB (FNP)
Entity type:Individual
Prefix:
First Name:MAHBOOB
Middle Name:
Last Name:LUTFY
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 W 6TH ST STE 105
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-1644
Mailing Address - Country:US
Mailing Address - Phone:888-873-6220
Mailing Address - Fax:
Practice Address - Street 1:1307 W 6TH ST STE 105
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-1644
Practice Address - Country:US
Practice Address - Phone:888-873-6220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-04
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95026413363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily