Provider Demographics
NPI:1639749328
Name:BUTLER, DIANA LUCILLE (RN)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:LUCILLE
Last Name:BUTLER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13190 S OUTER 40 RD
Mailing Address - Street 2:
Mailing Address - City:TOWN AND COUNTRY
Mailing Address - State:MO
Mailing Address - Zip Code:63017-5917
Mailing Address - Country:US
Mailing Address - Phone:573-355-3871
Mailing Address - Fax:
Practice Address - Street 1:13190 S OUTER 40 RD
Practice Address - Street 2:
Practice Address - City:TOWN AND COUNTRY
Practice Address - State:MO
Practice Address - Zip Code:63017-5917
Practice Address - Country:US
Practice Address - Phone:573-355-3871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-25
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO125964163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse