Healthcare Provider Details

I. General information

NPI: 1538989264
Provider Name (Legal Business Name): JUSTIN BUTLER PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2024
Last Update Date: 10/16/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1542 KINGSLEY AVE STE 136-137
ORANGE PARK FL
32073-4586
US

IV. Provider business mailing address

4153 FISHING CREEK LN
MIDDLEBURG FL
32068-3986
US

V. Phone/Fax

Practice location:
  • Phone: 239-690-6906
  • Fax:
Mailing address:
  • Phone: 904-210-4701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11035870
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: