Healthcare Provider Details

I. General information

NPI: 1992040448
Provider Name (Legal Business Name): MARY ELLEN PUCKETT REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2012
Last Update Date: 12/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12501 PROSPERITY DR 100
SILVER SPRING MD
20904-1689
US

IV. Provider business mailing address

12501 PROSPERITY DR 100
SILVER SPRING MD
20904-1689
US

V. Phone/Fax

Practice location:
  • Phone: 301-681-6730
  • Fax: 301-681-4268
Mailing address:
  • Phone: 301-681-6730
  • Fax: 301-681-4268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR196603
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: