Healthcare Provider Details

I. General information

NPI: 1407002207
Provider Name (Legal Business Name): MS. GWENDORIA BUCKLES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2008
Last Update Date: 01/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 WOOD ST
EUREKA CA
95501
US

IV. Provider business mailing address

720 WOOD ST
EUREKA CA
95501-4413
US

V. Phone/Fax

Practice location:
  • Phone: 707-268-2990
  • Fax:
Mailing address:
  • Phone: 707-268-2990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number811867
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN067802
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: