Provider Demographics
NPI:1194348078
Name:BUTLER, KHALIAH JEELAN
Entity type:Individual
Prefix:
First Name:KHALIAH
Middle Name:JEELAN
Last Name:BUTLER
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 1:1212 COLEMAN ST
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32310-6011
Mailing Address - Country:US
Mailing Address - Phone:850-800-6615
Mailing Address - Fax:
Practice Address - Street 1:1212 COLEMAN ST
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32310-6011
Practice Address - Country:US
Practice Address - Phone:850-800-6615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-26
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5237752164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty