Provider Demographics
NPI:1821543190
Name:BUCKNELL, REYNA MENDOZA (PT, DPT)
Entity Type:Individual
Prefix:MRS
First Name:REYNA
Middle Name:MENDOZA
Last Name:BUCKNELL
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3633 VISTA WAY
Mailing Address - Street 2:STE 101
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-4568
Mailing Address - Country:US
Mailing Address - Phone:407-376-1404
Mailing Address - Fax:
Practice Address - Street 1:3633 VISTA WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4568
Practice Address - Country:US
Practice Address - Phone:760-729-7298
Practice Address - Fax:760-729-7206
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-16
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT291779225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist