Provider Demographics
NPI:1871009654
Name:BUCKNER, MARCELLA (HEALTH CARE ADMINIST)
Entity Type:Individual
Prefix:
First Name:MARCELLA
Middle Name:
Last Name:BUCKNER
Suffix:
Gender:F
Credentials:HEALTH CARE ADMINIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14050 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92344-8096
Mailing Address - Country:US
Mailing Address - Phone:330-328-2114
Mailing Address - Fax:
Practice Address - Street 1:14050 PEARL ST
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92344-8096
Practice Address - Country:US
Practice Address - Phone:330-328-2114
Practice Address - Fax:760-533-9300
Is Sole Proprietor?:No
Enumeration Date:2017-12-15
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA463952905Medicaid
CA463952905OtherNON PROFIT