Basic Information
| Provider Information | |||||||||
| NPI: | 1295063790 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUTLER | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2680 GROSVENOR PL APT 1 | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271065244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367480065 | ||||||||
| FaxNumber: | 3367480065 | ||||||||
| Practice Location | |||||||||
| Address1: | 351 RIVERSIDE DR | ||||||||
| Address2: | |||||||||
| City: | MOUNT AIRY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270303877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367867079 | ||||||||
| FaxNumber: | 3367866312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2009 | ||||||||
| LastUpdateDate: | 11/23/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 2009006136 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.