Provider Demographics
NPI:1851435887
Name:BUCKLES, LISA KIM
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:KIM
Last Name:BUCKLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:KIM
Other - Last Name:BOLOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9040A JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:JBLM
Mailing Address - State:WA
Mailing Address - Zip Code:98431
Mailing Address - Country:US
Mailing Address - Phone:253-968-5828
Mailing Address - Fax:
Practice Address - Street 1:9040A JACKSON AVE
Practice Address - Street 2:
Practice Address - City:JBLM
Practice Address - State:WA
Practice Address - Zip Code:98431-8780
Practice Address - Country:US
Practice Address - Phone:253-353-9089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00160391163W00000X, 390200000X
WAAP60658000363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program