Provider Demographics
NPI:1295875334
Name:PELLETIER-BUTLER, PAULA (DM, MS, LM)
Entity type:Individual
Prefix:DR
First Name:PAULA
Middle Name:
Last Name:PELLETIER-BUTLER
Suffix:
Gender:F
Credentials:DM, MS, LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 W ASPEN AVE
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-5305
Mailing Address - Country:US
Mailing Address - Phone:289-556-0000
Mailing Address - Fax:
Practice Address - Street 1:401 W ASPEN AVE
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-5305
Practice Address - Country:US
Practice Address - Phone:206-679-1970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLM178176B00000X, 367A00000X
AZMT-17615225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPP987Medicare UPIN