Provider Demographics
NPI:1043299209
Name:BUCKLEY, THERESA S (FNP)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:S
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:L
Other - Last Name:STOVERN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:207 KING OLAF COURT
Mailing Address - Street 2:
Mailing Address - City:COLFAX
Mailing Address - State:WI
Mailing Address - Zip Code:54730
Mailing Address - Country:US
Mailing Address - Phone:715-962-2285
Mailing Address - Fax:715-962-2285
Practice Address - Street 1:207 KING OLAF CT
Practice Address - Street 2:
Practice Address - City:COLFAX
Practice Address - State:WI
Practice Address - Zip Code:54730-9517
Practice Address - Country:US
Practice Address - Phone:715-962-2285
Practice Address - Fax:715-962-2285
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2306363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41175800Medicaid
WI0433 20195Medicare ID - Type Unspecified
Q00326Medicare UPIN