Basic Information
| Provider Information | |||||||||
| NPI: | 1750363628 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KUTZKE | ||||||||
| FirstName: | DIANNE | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5127 | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982065127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252583900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3901 HOYT AVE | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982014918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253395456 | ||||||||
| FaxNumber: | 4258697201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 05/22/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP30001181 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 7023KU | 01 | WA | BLUE SHIELD | OTHER | 9607276 | 05 | WA | MEDICAID | 139617 | 01 | WA | LABOR & INDUSTRIES | OTHER | 1018078 | 05 | WA | MEDICAID | 200012131 | 01 | WA | MEDICARE RAILROAD | OTHER |