Provider Demographics
NPI:1689252207
Name:BUCKHALTER, TAMIKA R
Entity Type:Individual
Prefix:
First Name:TAMIKA
Middle Name:R
Last Name:BUCKHALTER
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 1:118 COPPERFIELD CT
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-9691
Mailing Address - Country:US
Mailing Address - Phone:815-614-8879
Mailing Address - Fax:
Practice Address - Street 1:8940 HWY 45 ALT SOUTH
Practice Address - Street 2:
Practice Address - City:CRAWFORD
Practice Address - State:MS
Practice Address - Zip Code:39743
Practice Address - Country:US
Practice Address - Phone:815-614-8879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-02
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS802330237343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)