Provider Demographics
NPI:1497087241
Name:BOUTTY, TERRY L (ARNP)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:L
Last Name:BOUTTY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 E ALTAMONTE DR
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-4802
Mailing Address - Country:US
Mailing Address - Phone:407-303-2305
Mailing Address - Fax:866-445-1446
Practice Address - Street 1:685 PALM SPRINGS DR
Practice Address - Street 2:STE 2A
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-7853
Practice Address - Country:US
Practice Address - Phone:407-830-5577
Practice Address - Fax:407-830-4164
Is Sole Proprietor?:No
Enumeration Date:2010-02-04
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2743122363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCW720VMedicare PIN
FLCW720WMedicare PIN