Healthcare Provider Details

I. General information

NPI: 1114311099
Provider Name (Legal Business Name): AYISHA BRIELLE BUCKLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2015
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 E 68TH ST STE J-130
NEW YORK NY
10065-4870
US

IV. Provider business mailing address

525 E 68TH ST STE J-130
NEW YORK NY
10065-4870
US

V. Phone/Fax

Practice location:
  • Phone: 954-816-8864
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number111488
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number299751
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number111488
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: