Healthcare Provider Details

I. General information

NPI: 1689285249
Provider Name (Legal Business Name): PUCKETT FAMILY MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2020
Last Update Date: 08/16/2020
Certification Date: 08/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6455 HIGHWAY 18
BRANDON MS
39042-7536
US

IV. Provider business mailing address

PO BOX 580
PUCKETT MS
39151-0580
US

V. Phone/Fax

Practice location:
  • Phone: 601-824-9490
  • Fax: 601-824-5855
Mailing address:
  • Phone: 601-824-9490
  • Fax: 601-824-5855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ASHELY M SHIVERS
Title or Position: OWNER
Credential: NP
Phone: 601-824-9490