Provider Demographics
NPI:1326122912
Name:BUCKLEY, SUSAN JOAN (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:JOAN
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:938 E ZERO ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:AINSWORTH
Mailing Address - State:NE
Mailing Address - Zip Code:69210-1555
Mailing Address - Country:US
Mailing Address - Phone:402-382-3145
Mailing Address - Fax:402-382-3147
Practice Address - Street 1:938 E ZERO ST
Practice Address - Street 2:SUITE B
Practice Address - City:AINSWORTH
Practice Address - State:NE
Practice Address - Zip Code:69210-1555
Practice Address - Country:US
Practice Address - Phone:402-382-3145
Practice Address - Fax:402-382-3147
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE110027363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025324900Medicaid
NE099783Medicare ID - Type Unspecified
NE10025324900Medicaid