Healthcare Provider Details

I. General information

NPI: 1114485067
Provider Name (Legal Business Name): CARISSA BUCKEY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2019
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5859 W TALAVI BLVD STE 100
GLENDALE AZ
85306-1870
US

IV. Provider business mailing address

5859 W TALAVI BLVD STE 100
GLENDALE AZ
85306-1870
US

V. Phone/Fax

Practice location:
  • Phone: 602-298-7777
  • Fax: 623-930-6060
Mailing address:
  • Phone: 602-298-7777
  • Fax: 623-930-6060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP11492
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: