Healthcare Provider Details

I. General information

NPI: 1962177576
Provider Name (Legal Business Name): COLLEEN ELIZABETH BUCKLEY RN, CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2021
Last Update Date: 07/07/2023
Certification Date: 08/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE
ROCHESTER NY
14642-0001
US

IV. Provider business mailing address

601 ELMWOOD AVE
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 585-757-5052
  • Fax:
Mailing address:
  • Phone: 585-757-5052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number673759
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number383281
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number383281
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: