Provider Demographics
NPI:1760713150
Name:BUTLER, DESERET ROBIN (LPN)
Entity Type:Individual
Prefix:MS
First Name:DESERET
Middle Name:ROBIN
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 1:2896 SAND BEACH RD
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-5651
Mailing Address - Country:US
Mailing Address - Phone:315-252-3920
Mailing Address - Fax:
Practice Address - Street 1:2896 SAND BEACH RD
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-5651
Practice Address - Country:US
Practice Address - Phone:315-252-3920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-25
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1736461164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1736461OtherNURSING LICENSE