Provider Demographics
NPI:1194129411
Name:BUCKLAND, PENNY R
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:R
Last Name:BUCKLAND
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 SW 7TH ST STE A205
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-2983
Mailing Address - Country:US
Mailing Address - Phone:877-522-1275
Mailing Address - Fax:833-888-7145
Practice Address - Street 1:8050 W RIFLEMAN ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9004
Practice Address - Country:US
Practice Address - Phone:877-522-1275
Practice Address - Fax:833-888-7145
Is Sole Proprietor?:No
Enumeration Date:2014-10-15
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP1459A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner