1871676049 NPI number — MS. MARILYN ELIZABETH BUCKLEY MSN, CFNP

Table of content: MS. MARILYN ELIZABETH BUCKLEY MSN, CFNP (NPI 1871676049)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871676049 NPI number — MS. MARILYN ELIZABETH BUCKLEY MSN, CFNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUCKLEY
Provider First Name:
MARILYN
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MSN, CFNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LOUIS
Provider Other First Name:
MARILYN
Provider Other Middle Name:
E
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSN, CPNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1871676049
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
117 S. BURGESS ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST BRANCH
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48661
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-343-1367
Provider Business Mailing Address Fax Number:
989-343-1427

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
117 S. BURGESS ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST BRANCH
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48661
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-343-1367
Provider Business Practice Location Address Fax Number:
989-343-1427
Provider Enumeration Date:
10/23/2006

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: 363L00000X , with the licence number:  4704118735 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 23D1031156 . This is a "CLIA NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 46273355 TYPE 10 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5008703250 . This is a "BCBS OF MICHIGAN PROV ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 5008703250 . This is a "BCBS OF MICHIGAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 200893159 . This is a "TAX ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4704118735 . This is a "STATE LIC NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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