Provider Demographics
NPI:1841361714
Name:BUCKNER, SHAREEN (FNP)
Entity type:Individual
Prefix:
First Name:SHAREEN
Middle Name:
Last Name:BUCKNER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5492 FRED HAGUEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-8413
Mailing Address - Country:US
Mailing Address - Phone:601-644-9809
Mailing Address - Fax:
Practice Address - Street 1:133 SCANLAN ST
Practice Address - Street 2:LA-Z-BOY SOUTH CLINIC
Practice Address - City:NEWTON
Practice Address - State:MS
Practice Address - Zip Code:39345-2329
Practice Address - Country:US
Practice Address - Phone:601-683-1375
Practice Address - Fax:601-683-4120
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR609536363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0118227Medicaid
R82522Medicare UPIN