Provider Demographics
NPI:1386158566
Name:BUTLER, REGINA ALISA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:ALISA
Last Name:BUTLER
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1163 NEAFIE AVE
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48342-1966
Mailing Address - Country:US
Mailing Address - Phone:248-221-2707
Mailing Address - Fax:
Practice Address - Street 1:44405 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-5023
Practice Address - Country:US
Practice Address - Phone:248-858-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-26
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704181194363LF0000X, 163WC0400X
SC81235163W00000X
SC21777363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management