Provider Demographics
NPI:1891991501
Name:KELLY ANN BUTLER FAMILY NURSE PRACTITIONER,PLLC
Entity Type:Organization
Organization Name:KELLY ANN BUTLER FAMILY NURSE PRACTITIONER,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:607-432-7900
Mailing Address - Street 1:438 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ONEONTA
Mailing Address - State:NY
Mailing Address - Zip Code:13820-2058
Mailing Address - Country:US
Mailing Address - Phone:607-432-7900
Mailing Address - Fax:607-432-7903
Practice Address - Street 1:438 MAIN ST
Practice Address - Street 2:
Practice Address - City:ONEONTA
Practice Address - State:NY
Practice Address - Zip Code:13820-2058
Practice Address - Country:US
Practice Address - Phone:607-432-7900
Practice Address - Fax:607-432-7903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY332310363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02848135Medicaid
NY02848135Medicaid