Provider Demographics
NPI:1821141524
Name:BUCKNAM, JUSTINE M (ARNP)
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:M
Last Name:BUCKNAM
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:JUSTINE
Other - Middle Name:MARIE
Other - Last Name:PERKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1003 S 5TH ST
Mailing Address - Street 2:3L
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4210
Mailing Address - Country:US
Mailing Address - Phone:253-403-1677
Mailing Address - Fax:
Practice Address - Street 1:1003 S 5TH ST
Practice Address - Street 2:3L
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4210
Practice Address - Country:US
Practice Address - Phone:253-403-1677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30007471363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily