Healthcare Provider Details

I. General information

NPI: 1265099303
Provider Name (Legal Business Name): SARAH EMILY BUCKNER RN, AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SARAH DICKEY

II. Dates (important events)

Enumeration Date: 05/23/2019
Last Update Date: 05/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 US HIGHWAY 61 STE G50
FESTUS MO
63028-4142
US

IV. Provider business mailing address

1120 MAYWOOD DR
EUREKA MO
63025-2766
US

V. Phone/Fax

Practice location:
  • Phone: 314-366-4874
  • Fax:
Mailing address:
  • Phone: 636-236-6958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2009023414
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP140436
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2018034003
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: