=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205023173
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TINA MARIE BUTT NP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2007
-----------------------------------------------------
Last Update Date | 03/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9485 MENTOR AVENUE SUITE 210
-----------------------------------------------------
City | MENTOR
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44060-8723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-255-5571
-----------------------------------------------------
Fax | 440-205-5744
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7590 AUBURN ROAD., SUITE 014 ATTN: MEDICAL STAFF
-----------------------------------------------------
City | CONCORD TWP
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44077-9176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-354-1899
-----------------------------------------------------
Fax | 440-354-1845
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WG0000X
-----------------------------------------------------
Taxonomy Name | General Practice Registered Nurse
-----------------------------------------------------
License Number | COA.09534-NP
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | APRN.CNP.09534
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------