Provider Demographics
NPI:1407866080
Name:BUTLER, JOAN P (MSN, FNP-C, PA-C)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:P
Last Name:BUTLER
Suffix:
Gender:F
Credentials:MSN, FNP-C, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 9TH ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-6248
Mailing Address - Country:US
Mailing Address - Phone:707-826-8633
Mailing Address - Fax:707-826-8638
Practice Address - Street 1:3304 RENNER DR
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-7102
Practice Address - Country:US
Practice Address - Phone:707-725-4477
Practice Address - Fax:707-725-9209
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAFNP12891363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN296119Medicaid
CAZZZ05658ZMedicare PIN