Provider Demographics
NPI:1609683960
Name:BUCKNER, TAKATIYA
Entity type:Individual
Prefix:
First Name:TAKATIYA
Middle Name:
Last Name:BUCKNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6415 VENANGO DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40258-2969
Mailing Address - Country:US
Mailing Address - Phone:502-999-4059
Mailing Address - Fax:
Practice Address - Street 1:901 S 4TH ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40203-3205
Practice Address - Country:US
Practice Address - Phone:502-585-9911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-11
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program