Provider Demographics
NPI:1538160650
Name:BUTLER, KELLY ANN (FNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:BUTLER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2580
Mailing Address - Country:US
Mailing Address - Phone:607-729-8156
Mailing Address - Fax:607-729-3982
Practice Address - Street 1:179 RIVER ST
Practice Address - Street 2:
Practice Address - City:ONEONTA
Practice Address - State:NY
Practice Address - Zip Code:13820-2239
Practice Address - Country:US
Practice Address - Phone:607-432-8477
Practice Address - Fax:607-432-3150
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF332310363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02848135Medicaid
NY02848135Medicaid
NYJ400060930Medicare PIN