Healthcare Provider Details

I. General information

NPI: 1609625037
Provider Name (Legal Business Name): LEAH BUCKINGHAM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2024
Last Update Date: 05/17/2024
Certification Date: 05/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

874 GALEN DR
STATE COLLEGE PA
16803-1164
US

IV. Provider business mailing address

874 GALEN DR
STATE COLLEGE PA
16803-1164
US

V. Phone/Fax

Practice location:
  • Phone: 989-202-5455
  • Fax:
Mailing address:
  • Phone: 989-202-5455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP029509
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: