Healthcare Provider Details

I. General information

NPI: 1659650455
Provider Name (Legal Business Name): STEPHANIE ANNE BUTLER FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2011
Last Update Date: 04/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 S MERCER AVE
BLOOMINGTON IL
61701-7107
US

IV. Provider business mailing address

1015 S MERCER AVE
BLOOMINGTON IL
61701-7107
US

V. Phone/Fax

Practice location:
  • Phone: 309-662-4321
  • Fax:
Mailing address:
  • Phone: 309-662-4321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209008930
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: