Provider Demographics
NPI:1215034764
Name:BUCKNER, PATRICIA DIANE (EDD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:DIANE
Last Name:BUCKNER
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:DIANE
Other - Last Name:NEILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:EDD
Mailing Address - Street 1:7513 DOVE VALLEY DRIVE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37221-2322
Mailing Address - Country:US
Mailing Address - Phone:615-662-8986
Mailing Address - Fax:
Practice Address - Street 1:6110 SHALLOWFORD RD
Practice Address - Street 2:
Practice Address - City:CHATTONOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421
Practice Address - Country:US
Practice Address - Phone:800-632-6074
Practice Address - Fax:866-341-7509
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2008-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP0000001865103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3686238Medicaid
TN3686233Medicare PIN