Provider Demographics
NPI:1164752903
Name:BUTLER-VISE, KELLY (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BUTLER-VISE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CARLISLE
Mailing Address - State:KY
Mailing Address - Zip Code:40311-1150
Mailing Address - Country:US
Mailing Address - Phone:859-289-4124
Mailing Address - Fax:859-289-4126
Practice Address - Street 1:107 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CARLISLE
Practice Address - State:KY
Practice Address - Zip Code:40311-1150
Practice Address - Country:US
Practice Address - Phone:859-289-4124
Practice Address - Fax:859-289-4126
Is Sole Proprietor?:No
Enumeration Date:2009-12-29
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1334363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100123820Medicaid