MEDICARE: PROF. LORI BUCKLEY MSN, RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WA2000X	Administrator Registered Nurse	R185850	MD
2	163WM0705X	Medical-Surgical Registered Nurse	R185850	MD
3	163WC1400X	College Health Registered Nurse	R185850	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	B240546501663	OTHER	MD	DRIVERS LICENSE

General Provider Information

NPI Number	:	1326656935
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PROF. LORI BUCKLEY MSN, RN

Provider Business Mailing Address
First Line	:	1901 WEST ST UNIT 204
Second Line	:
City	:	ANNAPOLIS
State	:	MD
Zip	:	21401-3935
Country	:	US
Telephone Number	:	410-758-7779
Fax Number	:

Provider Business Practice Location Address
First Line	:	1901 WEST ST UNIT 204
Second Line	:
City	:	ANNAPOLIS
State	:	MD
Zip	:	21401-3935
Country	:	US
Telephone Number	:	410-758-7779
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2020
Last Update Date	:	07/20/2020

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