MEDICARE: EBONY MONIQUE BUTTS LPN

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	164W00000X	Licensed Practical Nurse	334298	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	334298	OTHER	NY	LICENSE

General Provider Information

NPI Number	:	1346703402
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EBONY MONIQUE BUTTS LPN

Provider Business Mailing Address
First Line	:	3302 TOWNEHOUSE DR
Second Line	:
City	:	CORAM
State	:	NY
Zip	:	11727-2849
Country	:	US
Telephone Number	:	631-433-1132
Fax Number	:	631-846-8369

Provider Business Practice Location Address
First Line	:	49 OAKCREST AVE
Second Line	:
City	:	MIDDLE ISLAND
State	:	NY
Zip	:	11953-1415
Country	:	US
Telephone Number	:	632-995-2900
Fax Number	:

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

Provider Enumeration Date	:	04/07/2019
Last Update Date	:	04/07/2019

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