Provider Demographics
NPI:1427614726
Name:BUCKLES, AMBER RAYNEE
Entity type:Individual
Prefix:MRS
First Name:AMBER
Middle Name:RAYNEE
Last Name:BUCKLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 S 40TH AVE STE 18
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-3867
Mailing Address - Country:US
Mailing Address - Phone:509-965-0100
Mailing Address - Fax:509-902-8118
Practice Address - Street 1:1015 S 40TH AVE STE 18
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908-3867
Practice Address - Country:US
Practice Address - Phone:509-965-0100
Practice Address - Fax:509-902-8118
Is Sole Proprietor?:No
Enumeration Date:2019-05-13
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60934621225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA60934621OtherWASHINGTON STATE DEPARTMENT OF HEALTH