Provider Demographics
NPI:1366548372
Name:BUTALA, SUZANNE RACHELLE (NP)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:RACHELLE
Last Name:BUTALA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19121 BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-2307
Mailing Address - Country:US
Mailing Address - Phone:714-848-1522
Mailing Address - Fax:
Practice Address - Street 1:20701 BEACH BLVD
Practice Address - Street 2:#277
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-4908
Practice Address - Country:US
Practice Address - Phone:714-661-8439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANPF4529363LF0000X
CA256495363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANPC4529OtherNP CERTIFICATION
CABJ970YMedicare UPIN
CANPC4529OtherNP CERTIFICATION