Healthcare Provider Details

I. General information

NPI: 1801117171
Provider Name (Legal Business Name): KERRY LOUISE BUCKLEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2010
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 CHILD ST
JACKSONVILLE FL
32214-5005
US

IV. Provider business mailing address

236 N BRIDGE CREEK DR
ST JOHNS FL
32259-8882
US

V. Phone/Fax

Practice location:
  • Phone: 904-542-7419
  • Fax: 904-542-7839
Mailing address:
  • Phone: 301-537-1680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD0000048093
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: