Healthcare Provider Details

I. General information

NPI: 1962822817
Provider Name (Legal Business Name): ROSHANDA PUCKETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2014
Last Update Date: 04/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1309 GREENVIEW DR
GRIFFIN GA
30224-4048
US

IV. Provider business mailing address

1309 GREEN VIEW DRIVE
GRIFFIN GA
30224-7452
US

V. Phone/Fax

Practice location:
  • Phone: 678-603-1484
  • Fax:
Mailing address:
  • Phone: 678-603-1484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number465422576
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: