Provider Demographics
NPI:1942360227
Name:BUTTS, PRINCESS FAWN (LPN)
Entity Type:Individual
Prefix:
First Name:PRINCESS
Middle Name:FAWN
Last Name:BUTTS
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 1:303 W CORTLAND ST
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:NY
Mailing Address - Zip Code:13073-1009
Mailing Address - Country:US
Mailing Address - Phone:607-898-3620
Mailing Address - Fax:607-898-3620
Practice Address - Street 1:303 W CORTLAND ST
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:NY
Practice Address - Zip Code:13073-1009
Practice Address - Country:US
Practice Address - Phone:607-898-3620
Practice Address - Fax:607-898-3620
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY246946164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01925093Medicaid