Healthcare Provider Details

I. General information

NPI: 1225408057
Provider Name (Legal Business Name): SALLY DEE PUCKETT APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2015
Last Update Date: 11/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS WAY
LITTLE ROCK AR
72202-3500
US

IV. Provider business mailing address

1 CHILDREN'S WAY SLOT 844
LITTLE ROCK AR
72202-3500
US

V. Phone/Fax

Practice location:
  • Phone: 501-364-1977
  • Fax:
Mailing address:
  • Phone: 501-364-2090
  • Fax: 501-364-3929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberA004531
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: