Basic Information
| Provider Information | |||||||||
| NPI: | 1649730151 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUECHELE | ||||||||
| FirstName: | JACKIE LYNN | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12409 LORAIN AVE STE B | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441113515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162526670 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12409 LORAIN AVE STE B | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441113515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162526670 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2019 | ||||||||
| LastUpdateDate: | 03/21/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | PN093337L | PA | N | Nursing Service Providers | Licensed Practical Nurse | 164W00000X | LPN.131543.MEDS | OH | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.