Provider Demographics
NPI:1528218815
Name:BUCKLEY, BRIELLE MARIE (PA)
Entity Type:Individual
Prefix:
First Name:BRIELLE
Middle Name:MARIE
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:BRIELLE
Other - Middle Name:MARIE
Other - Last Name:BUCKLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1000 36TH ST
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-4862
Mailing Address - Country:US
Mailing Address - Phone:772-567-4311
Mailing Address - Fax:772-563-4641
Practice Address - Street 1:801 WELLNESS WAY STE 107
Practice Address - Street 2:
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958
Practice Address - Country:US
Practice Address - Phone:772-226-4200
Practice Address - Fax:772-581-5781
Is Sole Proprietor?:No
Enumeration Date:2008-09-24
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07418363A00000X
FLPA9110318363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8697NJOtherBCBS
TX328101601Medicaid
TX8663NDOtherBCBS
TX375401YKPWMedicare PIN
TX8663NDOtherBCBS