Provider Demographics
NPI:1346703402
Name:BUTTS, EBONY MONIQUE (LPN)
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:MONIQUE
Last Name:BUTTS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3302 TOWNEHOUSE DR
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-2849
Mailing Address - Country:US
Mailing Address - Phone:631-433-1132
Mailing Address - Fax:631-846-8369
Practice Address - Street 1:49 OAKCREST AVE
Practice Address - Street 2:
Practice Address - City:MIDDLE ISLAND
Practice Address - State:NY
Practice Address - Zip Code:11953-1415
Practice Address - Country:US
Practice Address - Phone:632-995-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-07
Last Update Date:2019-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY334298164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY334298OtherLICENSE