Provider Demographics
NPI:1871676049
Name:BUCKLEY, MARILYN ELIZABETH (MSN, CFNP)
Entity Type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:ELIZABETH
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:MSN, CFNP
Other - Prefix:MS
Other - First Name:MARILYN
Other - Middle Name:E
Other - Last Name:LOUIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, CPNP
Mailing Address - Street 1:117 S. BURGESS ST.
Mailing Address - Street 2:
Mailing Address - City:WEST BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48661
Mailing Address - Country:US
Mailing Address - Phone:989-343-1367
Mailing Address - Fax:989-343-1427
Practice Address - Street 1:117 S. BURGESS ST.
Practice Address - Street 2:
Practice Address - City:WEST BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48661
Practice Address - Country:US
Practice Address - Phone:989-343-1367
Practice Address - Fax:989-343-1427
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704118735363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI23D1031156OtherCLIA NUMBER
MI46273355 TYPE 10Medicaid
MI5008703250OtherBCBS OF MICHIGAN PROV ID
5008703250OtherBCBS OF MICHIGAN
MI200893159OtherTAX ID
MI4704118735OtherSTATE LIC NUMBER
MI46273355 TYPE 10Medicaid
MI23D1031156OtherCLIA NUMBER
MI4704118735OtherSTATE LIC NUMBER