MEDICARE: MRS. MARQUETTA DIONNE BUTLER RN, CRNA (PENDING)

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	367500000X	Certified Registered Nurse Anesthetist	RN176690	GA

General Provider Information

NPI Number	:	1598104408
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARQUETTA DIONNE BUTLER RN, CRNA (PENDING)

Provider Business Mailing Address
First Line	:	28110 DOVEWOOD CT
Second Line	:	APT. 303
City	:	BONITA SPRINGS
State	:	FL
Zip	:	34135-2885
Country	:	US
Telephone Number	:	678-908-4946
Fax Number	:

Provider Business Practice Location Address
First Line	:	1635 OLD 41 HWY NW
Second Line	:	SUITE 112-328
City	:	KENNESAW
State	:	GA
Zip	:	30152-4480
Country	:	US
Telephone Number	:	770-732-3664
Fax Number	:

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

Provider Enumeration Date	:	06/25/2013
Last Update Date	:	06/25/2013

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