Healthcare Provider Details

I. General information

NPI: 1013102599
Provider Name (Legal Business Name): KIMBERLY CHERYL BUTRUM RN GNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2007
Last Update Date: 05/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 E 12TH ST SUITE 101
AUSTIN TX
78701-1954
US

IV. Provider business mailing address

313 E 12TH ST SUITE 101
AUSTIN TX
78701-1954
US

V. Phone/Fax

Practice location:
  • Phone: 512-324-9660
  • Fax: 512-324-9651
Mailing address:
  • Phone: 512-324-9660
  • Fax: 512-324-9651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number724673
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: