Healthcare Provider Details

I. General information

NPI: 1588196133
Provider Name (Legal Business Name): ELISABETH MARIE BUTLER NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELISABETH MARIE BUTLER APRN

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 05/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 SWIFT ST
PROVIDENCE RI
02904-1437
US

IV. Provider business mailing address

114 SWIFT ST
PROVIDENCE RI
02904-1437
US

V. Phone/Fax

Practice location:
  • Phone: 401-529-8720
  • Fax:
Mailing address:
  • Phone: 401-529-8720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPRN01588
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: