Provider Demographics
NPI:1912616343
Name:BUTLER, BONNIE SUE
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:SUE
Last Name: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 1:746 AVRETT CIR
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-6676
Mailing Address - Country:US
Mailing Address - Phone:706-410-7596
Mailing Address - Fax:
Practice Address - Street 1:746 AVRETT CIR
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-6676
Practice Address - Country:US
Practice Address - Phone:706-410-7596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-15
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA46227251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health