Healthcare Provider Details

I. General information

NPI: 1568853216
Provider Name (Legal Business Name): MEGAN BUTCHER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2015
Last Update Date: 02/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7916 W JEFFERSON BLVD SUITE 112
FORT WAYNE IN
46804-4140
US

IV. Provider business mailing address

7803 PRESTON POINTE DR
FORT WAYNE IN
46804-5705
US

V. Phone/Fax

Practice location:
  • Phone: 260-969-7218
  • Fax:
Mailing address:
  • Phone: 260-403-4485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number28197696A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: