Healthcare Provider Details

I. General information

NPI: 1982001921
Provider Name (Legal Business Name): MARYJO BUTLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2014
Last Update Date: 11/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PL
SAINT LOUIS MO
63110-1002
US

IV. Provider business mailing address

1 CHILDRENS PL
SAINT LOUIS MO
63110-1002
US

V. Phone/Fax

Practice location:
  • Phone: 314-213-0156
  • Fax:
Mailing address:
  • Phone: 314-213-0156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number106853
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: