Healthcare Provider Details

I. General information

NPI: 1598249765
Provider Name (Legal Business Name): VICTORIA DANIELLE PUCKETT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VICTORIA DANIELLE KISSELL PA-C

II. Dates (important events)

Enumeration Date: 09/24/2018
Last Update Date: 01/03/2020
Certification Date: 01/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 BELMONT AVE
YOUNGSTOWN OH
44504-1003
US

IV. Provider business mailing address

1001 BELMONT AVE
YOUNGSTOWN OH
44504-1003
US

V. Phone/Fax

Practice location:
  • Phone: 330-747-6446
  • Fax: 330-747-6843
Mailing address:
  • Phone: 330-747-6446
  • Fax: 330-747-6843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number2192
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.006282RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: