Healthcare Provider Details

I. General information

NPI: 1164203303
Provider Name (Legal Business Name): TIANA J. BUTLER AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2023
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8888 LADUE RD STE 210
SAINT LOUIS MO
63124-2056
US

IV. Provider business mailing address

PO BOX 959354
SAINT LOUIS MO
63195-9354
US

V. Phone/Fax

Practice location:
  • Phone: 314-862-5044
  • Fax: 314-862-2734
Mailing address:
  • Phone: 314-862-5044
  • Fax: 314-862-2734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAG08230039
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209030358
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2023035141
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: