Provider Demographics
NPI:1740665389
Name:BUTKOVICH, KATHRYN JANE (CPNP-PC)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:JANE
Last Name:BUTKOVICH
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:JANE
Other - Last Name:HANDRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPNP-PC
Mailing Address - Street 1:1821 S WEBSTER AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-2253
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:
Practice Address - Street 1:1821 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301
Practice Address - Country:US
Practice Address - Phone:920-496-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-24
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI193019-30163W00000X
WI6620363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1740665389Medicaid
WI1740665389Medicaid