Provider Demographics
NPI:1104318575
Name:BUTTS, KELSIE ANN
Entity type:Individual
Prefix:
First Name:KELSIE
Middle Name:ANN
Last Name:BUTTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1487 E LASALLE DR
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-5653
Mailing Address - Country:US
Mailing Address - Phone:701-509-1699
Mailing Address - Fax:
Practice Address - Street 1:1487 E LASALLE DR
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-5653
Practice Address - Country:US
Practice Address - Phone:701-509-1699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-01
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty