Provider Demographics
NPI:1912795451
Name:LUTZ, ANGELA GAIL
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:GAIL
Last Name:LUTZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2627 W ALTORFER DR STE A
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-1867
Mailing Address - Country:US
Mailing Address - Phone:309-693-8448
Mailing Address - Fax:
Practice Address - Street 1:2627 W ALTORFER DR STE A
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-1867
Practice Address - Country:US
Practice Address - Phone:309-693-8448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-25
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist