Provider Demographics
NPI:1699165670
Name:BUCKLEY, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BUCKLEY
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 1:19 DOGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ROMNEY
Mailing Address - State:WV
Mailing Address - Zip Code:26757-8006
Mailing Address - Country:US
Mailing Address - Phone:304-671-6805
Mailing Address - Fax:
Practice Address - Street 1:19 DOGWOOD DR
Practice Address - Street 2:
Practice Address - City:ROMNEY
Practice Address - State:WV
Practice Address - Zip Code:26757-8006
Practice Address - Country:US
Practice Address - Phone:304-671-6805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-29
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0002086739164W00000X
WV32586164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse