Provider Demographics
NPI:1467024901
Name:BUCKLEW, MARY HANNAH (NP)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:HANNAH
Last Name:BUCKLEW
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 1:14724 HIGHWAY 15 N
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39339-6318
Mailing Address - Country:US
Mailing Address - Phone:662-773-7500
Mailing Address - Fax:
Practice Address - Street 1:1325 E FORTIFICATION ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2442
Practice Address - Country:US
Practice Address - Phone:601-354-4488
Practice Address - Fax:601-351-5980
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904350363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner