Provider Demographics
NPI:1619478989
Name:BUTANA, KIMBERLY (NP-C, CWON)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BUTANA
Suffix:
Gender:F
Credentials:NP-C, CWON
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 W GRAND AVE STE 3002
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45405-4722
Mailing Address - Country:US
Mailing Address - Phone:937-723-4231
Mailing Address - Fax:937-723-4545
Practice Address - Street 1:425 W GRAND AVE STE 3002
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-4722
Practice Address - Country:US
Practice Address - Phone:937-723-4231
Practice Address - Fax:937-723-4545
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.022300363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0270731Medicaid