Provider Demographics
NPI:1356941603
Name:MOMPOINT-BUTLER, INGRID
Entity type:Individual
Prefix:
First Name:INGRID
Middle Name:
Last Name:MOMPOINT-BUTLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1911 OAKLAND PARK AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43224-3630
Mailing Address - Country:US
Mailing Address - Phone:614-439-3168
Mailing Address - Fax:
Practice Address - Street 1:1911 OAKLAND PARK AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43224-3630
Practice Address - Country:US
Practice Address - Phone:614-439-3168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR795-P.A.363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical