Provider Demographics
NPI:1417192741
Name:BUCKLES, ANGLE RENEE (FNP)
Entity Type:Individual
Prefix:MISS
First Name:ANGLE
Middle Name:RENEE
Last Name:BUCKLES
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MISS
Other - First Name:RENEE
Other - Middle Name:
Other - Last Name:BUCKLES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:2514 WESLEY ST STE 102
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1764
Mailing Address - Country:US
Mailing Address - Phone:423-631-0236
Mailing Address - Fax:423-631-0237
Practice Address - Street 1:2514 WESLEY ST STE 102
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1764
Practice Address - Country:US
Practice Address - Phone:423-631-0236
Practice Address - Fax:423-631-0237
Is Sole Proprietor?:No
Enumeration Date:2008-12-16
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPRN0000014399363LF0000X, 363LP2300X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4243703OtherBLUECROSS BLUESHIELD
TN4243703OtherBLUECROSS BLUESHIELD