Provider Demographics
NPI:1033426168
Name:BUUCK, NICOLE S
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:S
Last Name:BUUCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:SURBECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:608 RIDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70001-6128
Mailing Address - Country:US
Mailing Address - Phone:504-309-8298
Mailing Address - Fax:
Practice Address - Street 1:608 RIDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001-6128
Practice Address - Country:US
Practice Address - Phone:504-309-8298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-10
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.Z11509174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist