Provider Demographics
NPI:1508091190
Name:BUTLER, LYDIA (167G00000X)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:BUTLER
Suffix:
Gender:F
Credentials:167G00000X
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 6 TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90012
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3126 N GLENROSE STREET
Practice Address - Street 2:
Practice Address - City:ALTADENA
Practice Address - State:CA
Practice Address - Zip Code:91001
Practice Address - Country:US
Practice Address - Phone:626-254-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-26
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN153640164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse