Healthcare Provider Details

I. General information

NPI: 1639353261
Provider Name (Legal Business Name): DANNIELLE ROSE PUCKETT PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DANNIELLE ROSE HUMPHREY PTA

II. Dates (important events)

Enumeration Date: 12/18/2007
Last Update Date: 12/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 MARGIE DR
WARNER ROBINS GA
31088-7818
US

IV. Provider business mailing address

301 MARGIE DR
WARNER ROBINS GA
31088-7818
US

V. Phone/Fax

Practice location:
  • Phone: 478-953-5800
  • Fax: 478-953-5800
Mailing address:
  • Phone: 478-953-5800
  • Fax: 478-953-5800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number001447
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: