Healthcare Provider Details

I. General information

NPI: 1689218950
Provider Name (Legal Business Name): RACHEL L PUCKETT PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2019
Last Update Date: 08/10/2023
Certification Date: 08/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1285 FRANCISCAN DR
LITCHFIELD IL
62056-1778
US

IV. Provider business mailing address

1025 S 6TH ST
SPRINGFIELD IL
62703-2499
US

V. Phone/Fax

Practice location:
  • Phone: 217-324-6127
  • Fax: 217-324-5959
Mailing address:
  • Phone: 217-528-7541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.007197
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: