Provider Demographics
NPI:1558411223
Name:HOUSTON, IDA MARILOU (ARNP)
Entity type:Individual
Prefix:
First Name:IDA
Middle Name:MARILOU
Last Name:HOUSTON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:IDA
Other - Middle Name:MARILOU
Other - Last Name:BUTALIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2730 N MCMULLEN BOOTH RD STE 201
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33761-3302
Mailing Address - Country:US
Mailing Address - Phone:727-725-5224
Mailing Address - Fax:727-799-2183
Practice Address - Street 1:2730 N MCMULLEN BOOTH RD STE 201
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761-3302
Practice Address - Country:US
Practice Address - Phone:727-725-5224
Practice Address - Fax:727-799-2183
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1512312207R00000X, 363L00000X
FLARNP 1512312363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL300796100Medicaid
FL300796100Medicaid
FLY4642YMedicare PIN