Healthcare Provider Details

I. General information

NPI: 1437561982
Provider Name (Legal Business Name): LAKESHA BUTLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2014
Last Update Date: 06/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 S MADISON ST
TUPELO MS
38801-4905
US

IV. Provider business mailing address

845 S MADISON ST
TUPELO MS
38801-4905
US

V. Phone/Fax

Practice location:
  • Phone: 662-377-2500
  • Fax: 662-377-2069
Mailing address:
  • Phone: 662-377-2500
  • Fax: 662-377-2069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberR883302
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: