Provider Demographics
NPI:1790752483
Name:BUTLER, LESLIE DIANE (ARNP)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:DIANE
Last Name:BUTLER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:DIANE
Other - Last Name:RICHISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1330
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070
Mailing Address - Country:US
Mailing Address - Phone:405-307-6630
Mailing Address - Fax:405-307-6660
Practice Address - Street 1:1019 N COUNCIL AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:BLANCHARD
Practice Address - State:OK
Practice Address - Zip Code:73010-8045
Practice Address - Country:US
Practice Address - Phone:405-515-0360
Practice Address - Fax:405-307-5596
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0058298363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100130320AMedicaid
S94333Medicare UPIN
OK100130320AMedicaid