Healthcare Provider Details

I. General information

NPI: 1023634383
Provider Name (Legal Business Name): BRIEANNA PUCKETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2020
Last Update Date: 12/16/2021
Certification Date: 12/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17401 WESTBURY DR
LOUISVILLE KY
40245-5483
US

IV. Provider business mailing address

17401 WESTBURY DR
LOUISVILLE KY
40245-5483
US

V. Phone/Fax

Practice location:
  • Phone: 336-707-0090
  • Fax:
Mailing address:
  • Phone: 336-707-0090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: