Healthcare Provider Details

I. General information

NPI: 1972375640
Provider Name (Legal Business Name): KEELIE PUCKETT RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2023
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4160 OCOEE ST N STE 8
CLEVELAND TN
37312-4886
US

IV. Provider business mailing address

280 SHADY HOLLOW CIR SE
CLEVELAND TN
37323-7742
US

V. Phone/Fax

Practice location:
  • Phone: 423-464-4357
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number260676
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: