Provider Demographics
NPI:1851435887
Name:BUCKLES, LISA KIM
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:KIM
Last Name:BUCKLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:KIM
Other - Last Name:BOLOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 TWINING ST BLDG 760
Mailing Address - Street 2:
Mailing Address - City:MAXWELL AFB
Mailing Address - State:AL
Mailing Address - Zip Code:36112-6027
Mailing Address - Country:US
Mailing Address - Phone:334-953-5200
Mailing Address - Fax:334-953-8607
Practice Address - Street 1:300 TWINING ST BLDG 760
Practice Address - Street 2:
Practice Address - City:MAXWELL AFB
Practice Address - State:AL
Practice Address - Zip Code:36112-6027
Practice Address - Country:US
Practice Address - Phone:334-953-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00160391390200000X, 163W00000X
WAAP60658000363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No163W00000XNursing Service ProvidersRegistered Nurse