Healthcare Provider Details

I. General information

NPI: 1144860529
Provider Name (Legal Business Name): FELICE MNL BUTLER ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2020
Last Update Date: 01/13/2020
Certification Date: 01/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 E SOUTHERN AVE
MESA AZ
85204-5220
US

IV. Provider business mailing address

2476 S NIELSON ST
GILBERT AZ
85295-7139
US

V. Phone/Fax

Practice location:
  • Phone: 480-472-5955
  • Fax:
Mailing address:
  • Phone: 434-660-9686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberATR-001702
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: