Healthcare Provider Details

I. General information

NPI: 1043208838
Provider Name (Legal Business Name): MARLA DIANNE BUCKLES FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 10/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 W CASABLANCA AVE 27 MEDICAL GROUP BLDG 1400 CANNON AFB
CLOVIS NM
88103-5009
US

IV. Provider business mailing address

208 W CASABLANCA AVE 27 MEDICAL GROUP BLDG 1400 CANNON AFB
CLOVIS NM
88101-5014
US

V. Phone/Fax

Practice location:
  • Phone: 505-784-6608
  • Fax: 505-784-6028
Mailing address:
  • Phone: 505-784-6605
  • Fax: 505-784-6028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number241753
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: