Healthcare Provider Details

I. General information

NPI: 1205371325
Provider Name (Legal Business Name): RHONDA KIM PUCKETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RHONDA KIM EARWOOD

II. Dates (important events)

Enumeration Date: 12/28/2016
Last Update Date: 11/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 RIVERBEND DR SW STE 120
ROME GA
30161
US

IV. Provider business mailing address

PO BOX 80883
ATHENS GA
30608-0883
US

V. Phone/Fax

Practice location:
  • Phone: 706-378-1202
  • Fax:
Mailing address:
  • Phone: 706-549-8114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN077416
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: