Healthcare Provider Details

I. General information

NPI: 1992071682
Provider Name (Legal Business Name): MAKEDA SHENAY BUTLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2012
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13800 HEACOCK ST STE 224
MORENO VALLEY CA
92553-8824
US

IV. Provider business mailing address

36369 TORREY PINES DR
BEAUMONT CA
92223-8016
US

V. Phone/Fax

Practice location:
  • Phone: 213-741-2276
  • Fax:
Mailing address:
  • Phone: 951-390-0318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number236262
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: