Provider Demographics
NPI:1679021117
Name:BUCKLEY, LIDA JOHNSON (MS, R,D, CD)
Entity Type:Individual
Prefix:MRS
First Name:LIDA
Middle Name:JOHNSON
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:MS, R,D, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:733 SPRINGLAKE DR
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37064-4839
Mailing Address - Country:US
Mailing Address - Phone:425-999-9638
Mailing Address - Fax:
Practice Address - Street 1:733 SPRINGLAKE DR
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37064-4839
Practice Address - Country:US
Practice Address - Phone:425-999-9638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-13
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNNU00001499133V00000X
WANU00001499133V00000X
TNLDN0000003954133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered