Provider Demographics
NPI:1396116257
Name:BUCKENROTH, GEORGIA M (LPN)
Entity type:Individual
Prefix:
First Name:GEORGIA
Middle Name:M
Last Name:BUCKENROTH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 W BAIRD ST
Mailing Address - Street 2:
Mailing Address - City:WEST LIBERTY
Mailing Address - State:OH
Mailing Address - Zip Code:43357-9707
Mailing Address - Country:US
Mailing Address - Phone:937-441-4234
Mailing Address - Fax:
Practice Address - Street 1:601 W BAIRD ST
Practice Address - Street 2:
Practice Address - City:WEST LIBERTY
Practice Address - State:OH
Practice Address - Zip Code:43357-9707
Practice Address - Country:US
Practice Address - Phone:937-441-4234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-16
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.153646-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse