Healthcare Provider Details

I. General information

NPI: 1356168793
Provider Name (Legal Business Name): CAROLINE MARJORIE PUCKETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2024
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 3RD AVE
ROCK ISLAND IL
61201-8840
US

IV. Provider business mailing address

2200 3RD AVE
ROCK ISLAND IL
61201-8840
US

V. Phone/Fax

Practice location:
  • Phone: 309-779-7500
  • Fax: 309-779-2372
Mailing address:
  • Phone: 309-779-7500
  • Fax: 309-779-2372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number41.368299
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: