=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235480682
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNETTE BUCKLEY RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2012
-----------------------------------------------------
Last Update Date | 09/25/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27 ORCHARD ST
-----------------------------------------------------
City | COS COB
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06807-2409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-449-8219
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 112881
-----------------------------------------------------
City | STAMFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06911-2881
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-449-8219
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 106707
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------