Healthcare Provider Details

I. General information

NPI: 1134680119
Provider Name (Legal Business Name): EMILY FAITH BUTTS CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: EMILY FAITH WIKER CPNP

II. Dates (important events)

Enumeration Date: 03/30/2019
Last Update Date: 03/21/2022
Certification Date: 03/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 HAMMETT RD
LAGRANGE GA
30241
US

IV. Provider business mailing address

301 MEDICAL DRIVE SUITE 504
LAGRANGE GA
30240
US

V. Phone/Fax

Practice location:
  • Phone: 706-880-7232
  • Fax:
Mailing address:
  • Phone: 706-812-2655
  • Fax: 706-812-2428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN268138
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN268138
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: