Healthcare Provider Details

I. General information

NPI: 1851680078
Provider Name (Legal Business Name): KIMBERLY JOY BUCK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2011
Last Update Date: 03/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 BROCKTON AVE STE 420
RIVERSIDE CA
92501-4026
US

IV. Provider business mailing address

4440 BROCKTON AVE STE 420
RIVERSIDE CA
92501-4026
US

V. Phone/Fax

Practice location:
  • Phone: 951-684-8020
  • Fax: 951-684-8090
Mailing address:
  • Phone: 951-684-8020
  • Fax: 951-684-8090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number19787
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: