Provider Demographics
NPI:1558663138
Name:BUTLER, POLLY (LPN, LMT)
Entity type:Individual
Prefix:
First Name:POLLY
Middle Name:
Last Name:BUTLER
Suffix:
Gender:F
Credentials:LPN, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:649 CTY RT 20
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-5613
Mailing Address - Country:US
Mailing Address - Phone:315-342-6515
Mailing Address - Fax:
Practice Address - Street 1:649 CTY RT 20
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-5613
Practice Address - Country:US
Practice Address - Phone:315-342-6515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-02
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY272362164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse