Provider Demographics
NPI:1245038819
Name:BUCKENDAHL, MARY BETH
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:BUCKENDAHL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:BETH
Other - Last Name:DIAZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:84911 560TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOSKINS
Mailing Address - State:NE
Mailing Address - Zip Code:68740-4050
Mailing Address - Country:US
Mailing Address - Phone:402-316-8474
Mailing Address - Fax:
Practice Address - Street 1:84911 560TH AVE
Practice Address - Street 2:
Practice Address - City:HOSKINS
Practice Address - State:NE
Practice Address - Zip Code:68740-4050
Practice Address - Country:US
Practice Address - Phone:402-316-8474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-07
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE372600000X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No372600000XNursing Service Related ProvidersAdult Companion