Healthcare Provider Details

I. General information

NPI: 1952974206
Provider Name (Legal Business Name): LAURA MARIE BUTCH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2021
Last Update Date: 07/22/2021
Certification Date: 07/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5045 W GRANDE MARKET DR
APPLETON WI
54913-8517
US

IV. Provider business mailing address

3421 W HERITAGE AVE
APPLETON WI
54914-1005
US

V. Phone/Fax

Practice location:
  • Phone: 920-886-9380
  • Fax:
Mailing address:
  • Phone: 920-858-4347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number10124
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: