MEDICARE: KELECHI BUTLER APN-CRNA

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	364S00000X	Clinical Nurse Specialist	26NR16538300	NJ
2	367500000X	Certified Registered Nurse Anesthetist	554549	NY

General Provider Information

NPI Number	:	1760876817
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELECHI BUTLER APN-CRNA

Provider Business Mailing Address
First Line	:	19 DOREEN DR
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10303-2136
Country	:	US
Telephone Number	:	646-318-0428
Fax Number	:

Provider Business Practice Location Address
First Line	:	19 DOREEN DR
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10303-2136
Country	:	US
Telephone Number	:	646-318-0428
Fax Number	:

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

Provider Enumeration Date	:	03/26/2015
Last Update Date	:	01/22/2019

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