Provider Demographics
NPI:1295365955
Name:BUCKMAN, MICHELLE (RN, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BUCKMAN
Suffix:
Gender:F
Credentials:RN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25885 AMAPOLAS ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-2503
Mailing Address - Country:US
Mailing Address - Phone:760-408-3069
Mailing Address - Fax:
Practice Address - Street 1:312 BROOKSIDE AVE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4608
Practice Address - Country:US
Practice Address - Phone:760-408-3069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95011953363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health