Provider Demographics
NPI:1033480439
Name:BUTALA, LORI (RN)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:
Last Name:BUTALA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 SW CENTURY AVE
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-4274
Mailing Address - Country:US
Mailing Address - Phone:772-336-3871
Mailing Address - Fax:
Practice Address - Street 1:1202 SW CENTURY AVE
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-4274
Practice Address - Country:US
Practice Address - Phone:772-336-3871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN1637672163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health