Provider Demographics
NPI:1750513370
Name:BOUTTE, LEVON DAWNTISE (LVN)
Entity type:Individual
Prefix:
First Name:LEVON
Middle Name:DAWNTISE
Last Name:BOUTTE
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11326 RIO CAMINO CT
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92337-7936
Mailing Address - Country:US
Mailing Address - Phone:909-549-9312
Mailing Address - Fax:
Practice Address - Street 1:11326 RIO CAMINO CT
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92337-7936
Practice Address - Country:US
Practice Address - Phone:909-549-9312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-14
Last Update Date:2009-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 197706164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse