Provider Demographics
NPI:1629264767
Name:BUCK, KIMBERLY M (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:M
Last Name:BUCK
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39350 9 MILE RD
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-9164
Mailing Address - Country:US
Mailing Address - Phone:313-570-6360
Mailing Address - Fax:
Practice Address - Street 1:39350 9 MILE RD
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-9164
Practice Address - Country:US
Practice Address - Phone:313-570-6360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-21
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704176196363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP34780085Medicare PIN