1790752483 NPI number — LESLIE DIANE BUTLER ARNP

Table of content: LESLIE DIANE BUTLER ARNP (NPI 1790752483)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790752483 NPI number — LESLIE DIANE BUTLER ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUTLER
Provider First Name:
LESLIE
Provider Middle Name:
DIANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RICHISON
Provider Other First Name:
LESLIE
Provider Other Middle Name:
DIANE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1790752483
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1330
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORMAN
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-307-6630
Provider Business Mailing Address Fax Number:
405-307-6660

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1019 N COUNCIL AVE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
BLANCHARD
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73010-8045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-515-0360
Provider Business Practice Location Address Fax Number:
405-307-5596
Provider Enumeration Date:
03/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  R0058298 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100130320A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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