Provider Demographics
NPI:1972616332
Name:BUCKELS, CAROL A (FNP-BC)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:A
Last Name:BUCKELS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 S RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-3331
Mailing Address - Country:US
Mailing Address - Phone:601-835-0077
Mailing Address - Fax:601-835-0095
Practice Address - Street 1:201 S RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-3331
Practice Address - Country:US
Practice Address - Phone:601-835-0077
Practice Address - Fax:601-835-0095
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR550191363L00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124865Medicaid
MS00124865Medicaid
MSS54628Medicare UPIN