Provider Demographics
NPI:1215935549
Name:BUTLER, MANDY JO (FNP)
Entity type:Individual
Prefix:MRS
First Name:MANDY
Middle Name:JO
Last Name:BUTLER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:MANDY
Other - Middle Name:JO
Other - Last Name:SIZEMORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:209 ELM ST
Mailing Address - Street 2:
Mailing Address - City:CLOVERPORT
Mailing Address - State:KY
Mailing Address - Zip Code:40111-1324
Mailing Address - Country:US
Mailing Address - Phone:270-788-3000
Mailing Address - Fax:
Practice Address - Street 1:209 ELM ST
Practice Address - Street 2:
Practice Address - City:CLOVERPORT
Practice Address - State:KY
Practice Address - Zip Code:40111-1324
Practice Address - Country:US
Practice Address - Phone:270-788-3000
Practice Address - Fax:270-788-6201
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4083P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78010758Medicaid
KY000000311345OtherBCBS
KY50003764OtherPASSPORT
KY50003764OtherPASSPORT
KY0568704Medicare ID - Type Unspecified