Provider Demographics
NPI:1790585396
Name:BUTLER, SHEVONDA NICOLE
Entity type:Individual
Prefix:
First Name:SHEVONDA
Middle Name:NICOLE
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 1:990 PEACHTREE INDUSTRIAL BLVD UNIT 913
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-5209
Mailing Address - Country:US
Mailing Address - Phone:470-518-7273
Mailing Address - Fax:
Practice Address - Street 1:990 PEACHTREE INDUSTRIAL BLVD UNIT 913
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-5209
Practice Address - Country:US
Practice Address - Phone:470-518-7273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-14
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICN0028861091376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide