Healthcare Provider Details

I. General information

NPI: 1639461189
Provider Name (Legal Business Name): PHYLLIS SUSAN BUTLER APN-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2011
Last Update Date: 02/06/2021
Certification Date: 02/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4313 S PLEASANT CROSSING BLVD
ROGERS AR
72758-1347
US

IV. Provider business mailing address

860 HIGHWAY 62 E STE 10
MOUNTAIN HOME AR
72653-3200
US

V. Phone/Fax

Practice location:
  • Phone: 479-947-4003
  • Fax: 870-424-3089
Mailing address:
  • Phone: 870-424-3181
  • Fax: 870-424-3089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberA03401 ANP
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: