Provider Demographics
NPI:1578934535
Name:BUTLER, KIMBERLY SUE (NP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUE
Last Name:BUTLER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:SUE
Other - Last Name:DONOVAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1115
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97709-1115
Mailing Address - Country:US
Mailing Address - Phone:541-382-1395
Mailing Address - Fax:541-382-6576
Practice Address - Street 1:339 SW CENTURY DR STE 101
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1199
Practice Address - Country:US
Practice Address - Phone:541-382-1395
Practice Address - Fax:541-382-6576
Is Sole Proprietor?:No
Enumeration Date:2015-10-15
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201507448NPPP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health