Healthcare Provider Details

I. General information

NPI: 1669792735
Provider Name (Legal Business Name): ALTHEA M BUCKNER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2010
Last Update Date: 04/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7975 LAKE UNDERHILL RD STE 220B
ORLANDO FL
32822-8202
US

IV. Provider business mailing address

501 SE OSCEOLA ST STE 301
STUART FL
34994-2347
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-6772
  • Fax: 407-303-6775
Mailing address:
  • Phone: 772-223-5955
  • Fax: 772-223-5954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9192140
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberARNP 9192140
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: