Provider Demographics
NPI:1467803049
Name:BUTLER, MALLORY ANN (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:ANN
Last Name:BUTLER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MRS
Other - First Name:MALLORY
Other - Middle Name:
Other - Last Name:LEVERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:325 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:RED BUN
Mailing Address - State:IL
Mailing Address - Zip Code:62278
Mailing Address - Country:US
Mailing Address - Phone:618-282-3831
Mailing Address - Fax:618-282-5476
Practice Address - Street 1:325 SPRING ST
Practice Address - Street 2:
Practice Address - City:RED BUN
Practice Address - State:IL
Practice Address - Zip Code:62278
Practice Address - Country:US
Practice Address - Phone:618-282-3831
Practice Address - Fax:618-282-5476
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-24
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016018336363LF0000X
IL209014336363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily