Provider Demographics
NPI:1265615504
Name:BUCKLEY, KIMBERLY M (ARNP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21107 DONAHOO RD
Mailing Address - Street 2:
Mailing Address - City:TONGANOXIE
Mailing Address - State:KS
Mailing Address - Zip Code:66086-4153
Mailing Address - Country:US
Mailing Address - Phone:913-742-4084
Mailing Address - Fax:913-742-4086
Practice Address - Street 1:21107 DONAHOO RD
Practice Address - Street 2:
Practice Address - City:TONGANOXIE
Practice Address - State:KS
Practice Address - Zip Code:66086-4153
Practice Address - Country:US
Practice Address - Phone:913-742-4084
Practice Address - Fax:913-742-4086
Is Sole Proprietor?:No
Enumeration Date:2007-12-10
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005009417363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2005009417OtherLICENSE
KS53-46082-081OtherARNP - KS