Provider Demographics
NPI:1639491756
Name:BUCK, KILEY LANE
Entity Type:Individual
Prefix:
First Name:KILEY
Middle Name:LANE
Last Name:BUCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KILEY
Other - Middle Name:LANE
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4121 N MOZART ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-2708
Mailing Address - Country:US
Mailing Address - Phone:217-741-0404
Mailing Address - Fax:
Practice Address - Street 1:4646 N MARINE DR
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5759
Practice Address - Country:US
Practice Address - Phone:773-564-5355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-16
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041 342623163W00000X
MO2006003604163W00000X
IL209008047367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse