Provider Demographics
NPI:1669448643
Name:KIMBALL-BUTLER, DAPHENE LUVATA (RNPCMCLCSANE)
Entity Type:Individual
Prefix:MS
First Name:DAPHENE
Middle Name:LUVATA
Last Name:KIMBALL-BUTLER
Suffix:
Gender:F
Credentials:RNPCMCLCSANE
Other - Prefix:MS
Other - First Name:DAPHENE
Other - Middle Name:LUVATA
Other - Last Name:KIMBALL-WILLIAMSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RNPCMCLCSANE
Mailing Address - Street 1:40 BLAKE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30014-5016
Mailing Address - Country:US
Mailing Address - Phone:706-650-5793
Mailing Address - Fax:770-786-2223
Practice Address - Street 1:4778 N HENRY BLVD
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-3566
Practice Address - Country:US
Practice Address - Phone:706-650-5793
Practice Address - Fax:770-786-2223
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN136141163WC1500X, 163WC0400X, 163WL0100X, 163WM0102X, 163WC1600X, 163WW0000X
SCR73283163WC0400X, 163WC1500X, 163WL0100X, 163WM0102X, 163WC1600X, 163WX0002X, 163WP1700X, 163WW0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn
No163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff Development
No163WW0000XNursing Service ProvidersRegistered NurseWound Care
No163WX0002XNursing Service ProvidersRegistered NurseObstetric, High-Risk
No163WP1700XNursing Service ProvidersRegistered NursePerinatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000847459BMedicaid
GA000847459AMedicaid