MEDICARE: MRS. LORI BUTALA RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WP0808X	Psychiatric/Mental Health Registered Nurse	RN1637672	FL

General Provider Information

NPI Number	:	1033480439
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LORI BUTALA RN

Provider Business Mailing Address
First Line	:	1202 SW CENTURY AVE
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34953-4274
Country	:	US
Telephone Number	:	772-336-3871
Fax Number	:

Provider Business Practice Location Address
First Line	:	1202 SW CENTURY AVE
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34953-4274
Country	:	US
Telephone Number	:	772-336-3871
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/18/2012
Last Update Date	:	01/18/2012

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