Provider Demographics
NPI:1477044527
Name:BUCKNER, KATELYN MARCEL
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:MARCEL
Last Name:BUCKNER
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 1:240 CAIN DR
Mailing Address - Street 2:
Mailing Address - City:BLOUNTVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37617-4822
Mailing Address - Country:US
Mailing Address - Phone:423-330-3014
Mailing Address - Fax:
Practice Address - Street 1:130 W RAVINE RD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660
Practice Address - Country:US
Practice Address - Phone:423-224-5550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-24
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN24173363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily