Provider Demographics
NPI:1568824787
Name:BUCKLEY, KRISTA (MD)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 COLCHESTER AVE
Mailing Address - Street 2:MS 259PA4
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-1473
Mailing Address - Country:US
Mailing Address - Phone:802-847-2700
Mailing Address - Fax:
Practice Address - Street 1:130 FISHER RD UNIT 1
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:VT
Practice Address - Zip Code:05602-8132
Practice Address - Country:US
Practice Address - Phone:802-371-4316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-26
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-00142502084P0800X
VT060-0004483390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program