Provider Demographics
NPI:1366153413
Name:LUTZ, MARC (PMHNP)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:LUTZ
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18031 ADRIFT RD
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-8471
Mailing Address - Country:US
Mailing Address - Phone:407-205-8822
Mailing Address - Fax:866-404-4006
Practice Address - Street 1:18031 ADRIFT RD
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-8471
Practice Address - Country:US
Practice Address - Phone:407-205-8822
Practice Address - Fax:866-404-4006
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-09
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9485045163W00000X
FL11023551363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse