Provider Demographics
NPI:1619276094
Name:BUTLER, GRADERIAH LA'TIFAH (LPN)
Entity Type:Individual
Prefix:
First Name:GRADERIAH
Middle Name:LA'TIFAH
Last Name:BUTLER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 DANUBE DR
Mailing Address - Street 2:APT 204
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-6192
Mailing Address - Country:US
Mailing Address - Phone:513-226-7590
Mailing Address - Fax:
Practice Address - Street 1:111 DANUBE DR
Practice Address - Street 2:APT 204
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-6192
Practice Address - Country:US
Practice Address - Phone:513-226-7590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-24
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH140420164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse