Provider Demographics
NPI:1366826463
Name:BUCKLEY, MARVALIN MAE
Entity Type:Individual
Prefix:
First Name:MARVALIN
Middle Name:MAE
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3464 WILSON AVE APT 1C
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-2327
Mailing Address - Country:US
Mailing Address - Phone:718-696-2374
Mailing Address - Fax:
Practice Address - Street 1:3464 WILSON AVE
Practice Address - Street 2:APT 1 C
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469
Practice Address - Country:US
Practice Address - Phone:718-696-2374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY264496164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse