Provider Demographics
NPI:1235909599
Name:BUCKLEY, JOSEPHINE (RD)
Entity Type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8808 SHERYL ANN DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63126-2132
Mailing Address - Country:US
Mailing Address - Phone:314-580-6036
Mailing Address - Fax:
Practice Address - Street 1:320 GRAVOIS RD # 210-230
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-4122
Practice Address - Country:US
Practice Address - Phone:636-600-0446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021035601133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered