Healthcare Provider Details

I. General information

NPI: 1114322864
Provider Name (Legal Business Name): LISAMARIE S BUCKLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2014
Last Update Date: 10/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1759 ASHBOURNE DR
YARDLEY PA
19067-3955
US

IV. Provider business mailing address

1759 ASHBOURNE DR
YARDLEY PA
19067-3955
US

V. Phone/Fax

Practice location:
  • Phone: 215-579-9127
  • Fax:
Mailing address:
  • Phone: 215-579-9127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP013479
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN352442L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: