Provider Demographics
NPI:1043459167
Name:LOTZ, TERA L (CNP)
Entity type:Individual
Prefix:
First Name:TERA
Middle Name:L
Last Name:LOTZ
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 BYRON CENTER AVE SW # MC845
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9686
Mailing Address - Country:US
Mailing Address - Phone:616-252-7200
Mailing Address - Fax:
Practice Address - Street 1:5900 BYRON CENTER AVE SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9686
Practice Address - Country:US
Practice Address - Phone:616-252-5202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-12
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704236439363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1043459167Medicaid