Provider Demographics
NPI:1669792735
Name:BUCKNER, ALTHEA M (APRN)
Entity type:Individual
Prefix:
First Name:ALTHEA
Middle Name:M
Last Name:BUCKNER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:501 SE OSCEOLA ST
Mailing Address - Street 2:STE 301
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-2347
Mailing Address - Country:US
Mailing Address - Phone:772-223-5955
Mailing Address - Fax:772-223-5954
Practice Address - Street 1:7975 LAKE UNDERHILL RD STE 220B
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-8202
Practice Address - Country:US
Practice Address - Phone:407-303-6772
Practice Address - Fax:407-303-6775
Is Sole Proprietor?:No
Enumeration Date:2010-06-10
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLARNP9192140363LF0000X
FLARNP 9192140363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013940000Medicaid