Healthcare Provider Details

I. General information

NPI: 1619478989
Provider Name (Legal Business Name): KIMBERLY BUTANA NP-C, CWON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2018
Last Update Date: 11/24/2020
Certification Date: 11/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 W GRAND AVE STE 3002
DAYTON OH
45405-4722
US

IV. Provider business mailing address

425 W GRAND AVE STE 3002
DAYTON OH
45405-4722
US

V. Phone/Fax

Practice location:
  • Phone: 937-723-4231
  • Fax: 937-723-4545
Mailing address:
  • Phone: 937-723-4231
  • Fax: 937-723-4545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.022300
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: