Provider Demographics
NPI:1134645344
Name:BUTNER, MARISSA
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:BUTNER
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 1:687 BIRD CT
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069-7374
Mailing Address - Country:US
Mailing Address - Phone:760-803-5219
Mailing Address - Fax:
Practice Address - Street 1:1500 S AVE K
Practice Address - Street 2:ENMU 3053
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130
Practice Address - Country:US
Practice Address - Phone:575-562-2160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-18
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program