Healthcare Provider Details

I. General information

NPI: 1386571404
Provider Name (Legal Business Name): NICOLE BUCKMAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 W THUNDERBIRD RD
GLENDALE AZ
85306-4622
US

IV. Provider business mailing address

12538 W MILTON DR
PEORIA AZ
85383-5013
US

V. Phone/Fax

Practice location:
  • Phone: 602-865-5555
  • Fax:
Mailing address:
  • Phone: 602-622-3421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number303708
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: