Healthcare Provider Details

I. General information

NPI: 1881631232
Provider Name (Legal Business Name): KRISTEN NICHOLE PUCKET PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 07/15/2022
Certification Date: 07/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3747 SW RAINTREE DR
LEES SUMMIT MO
64082-4606
US

IV. Provider business mailing address

1200 CORPORATE DR STE 400
HOOVER AL
35242-5424
US

V. Phone/Fax

Practice location:
  • Phone: 816-537-5648
  • Fax: 816-537-5649
Mailing address:
  • Phone: 423-238-7217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2005007067
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: