Provider Demographics
NPI:1427501477
Name:BOUTTE, SHALITA
Entity type:Individual
Prefix:
First Name:SHALITA
Middle Name:
Last Name:BOUTTE
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 1:500 HANCOCK ST
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-4224
Mailing Address - Country:US
Mailing Address - Phone:989-272-7291
Mailing Address - Fax:
Practice Address - Street 1:500 HANCOCK ST
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-4224
Practice Address - Country:US
Practice Address - Phone:989-272-7291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-26
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker