=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790241032
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LATOYA BUCKNOR NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2019
-----------------------------------------------------
Last Update Date | 02/12/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13436 246TH ST
-----------------------------------------------------
City | ROSEDALE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11422-1445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-283-8536
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13436 246TH ST
-----------------------------------------------------
City | ROSEDALE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11422-1445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-283-8536
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | F308989-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------