Provider Demographics
NPI:1740668599
Name:BUCKINGHAM, DEBORAH
Entity type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:
Last Name:BUCKINGHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:DEBORAH
Other - Middle Name:BERNICE
Other - Last Name:BUCKINGHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PCA
Mailing Address - Street 1:PO BOX 487
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:OH
Mailing Address - Zip Code:43138-0487
Mailing Address - Country:US
Mailing Address - Phone:740-816-5305
Mailing Address - Fax:
Practice Address - Street 1:22010 E SAMS CREEK RD
Practice Address - Street 2:
Practice Address - City:LAURELVILLE
Practice Address - State:OH
Practice Address - Zip Code:43135-9221
Practice Address - Country:US
Practice Address - Phone:740-816-5305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-13
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH25463743747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2546374Medicaid