Healthcare Provider Details

I. General information

NPI: 1518836121
Provider Name (Legal Business Name): DESTINY RICKI BUTLER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2025
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6340 SECURITY BLVD
GWYNN OAK MD
21207-5173
US

IV. Provider business mailing address

6340 SECURITY BLVD
GWYNN OAK MD
21207-5173
US

V. Phone/Fax

Practice location:
  • Phone: 443-909-9869
  • Fax:
Mailing address:
  • Phone: 443-909-9869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR254665
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR254665
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: