Provider Demographics
NPI:1447912258
Name:LUTZ, ALYSSA MARIE
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:MARIE
Last Name:LUTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-2353
Mailing Address - Country:US
Mailing Address - Phone:516-965-4270
Mailing Address - Fax:
Practice Address - Street 1:180 1ST AVE
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA PARK
Practice Address - State:NY
Practice Address - Zip Code:11762-2353
Practice Address - Country:US
Practice Address - Phone:516-965-4270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-08
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist