Provider Demographics
NPI:1528686987
Name:BUTLER, EBONY MICHELLE
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:MICHELLE
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 1:2401 2ND ST NW APT 70
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-4942
Mailing Address - Country:US
Mailing Address - Phone:407-319-8694
Mailing Address - Fax:
Practice Address - Street 1:2401 2ND ST NW APT 70
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4942
Practice Address - Country:US
Practice Address - Phone:407-319-8694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-10
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5224604164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse