Provider Demographics
NPI:1083664775
Name:LUTZ, KACIE NOELLE (MD)
Entity type:Individual
Prefix:
First Name:KACIE
Middle Name:NOELLE
Last Name:LUTZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 PRIMERA BLVD
Mailing Address - Street 2:SUITE #135
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-2112
Mailing Address - Country:US
Mailing Address - Phone:407-321-0085
Mailing Address - Fax:407-328-7658
Practice Address - Street 1:735 PRIMERA BLVD
Practice Address - Street 2:SUITE #135
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-2112
Practice Address - Country:US
Practice Address - Phone:407-321-0085
Practice Address - Fax:407-328-7658
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93233208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics