Healthcare Provider Details

I. General information

NPI: 1245546662
Provider Name (Legal Business Name): KAYNA BETH PUCKETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2010
Last Update Date: 01/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 TOWNSGATE PLZ
CLOVIS NM
88101-3714
US

IV. Provider business mailing address

202 E EARLL DR
PHOENIX AZ
85012-2634
US

V. Phone/Fax

Practice location:
  • Phone: 575-742-2620
  • Fax: 575-742-3182
Mailing address:
  • Phone: 575-742-2620
  • Fax: 575-742-3182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: