Healthcare Provider Details

I. General information

NPI: 1952888216
Provider Name (Legal Business Name): KAMI SUE PUCKETT RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2018
Last Update Date: 04/23/2021
Certification Date: 04/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

859 E MELTON DR
JAY OK
74346-2704
US

IV. Provider business mailing address

859 E MELTON DR
JAY OK
74346-2704
US

V. Phone/Fax

Practice location:
  • Phone: 918-253-1700
  • Fax:
Mailing address:
  • Phone: 918-253-1740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number65518
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR0134475
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: