Healthcare Provider Details

I. General information

NPI: 1326892480
Provider Name (Legal Business Name): JACQUELINE PUCKETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2024
Last Update Date: 04/15/2024
Certification Date: 04/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 DON WICKHAM DR
CLERMONT FL
34711-1979
US

IV. Provider business mailing address

168 CHAUCER AVE
DAVENPORT FL
33896-3078
US

V. Phone/Fax

Practice location:
  • Phone: 352-394-4071
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9548199
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: