Provider Demographics
NPI:1588540330
Name:BUCKLEY, KELSEY (MFN)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:BUCKLEY
Suffix:
Gender:X
Credentials:MFN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 N REIMAN RD
Mailing Address - Street 2:
Mailing Address - City:GENOA
Mailing Address - State:OH
Mailing Address - Zip Code:43430-9752
Mailing Address - Country:US
Mailing Address - Phone:419-349-1428
Mailing Address - Fax:
Practice Address - Street 1:2150 N REIMAN RD
Practice Address - Street 2:
Practice Address - City:GENOA
Practice Address - State:OH
Practice Address - Zip Code:43430-9752
Practice Address - Country:US
Practice Address - Phone:419-349-1428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-14
Last Update Date:2025-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH10842133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered