Healthcare Provider Details

I. General information

NPI: 1164295408
Provider Name (Legal Business Name): HAILEY PUCKETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2023
Last Update Date: 02/26/2025
Certification Date: 02/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16110 MCARTHUR ST
MANCHESTER TN
37388
US

IV. Provider business mailing address

155 HOSPITAL RD SUITE C
WARTRACE TN
37183-3030
US

V. Phone/Fax

Practice location:
  • Phone: 931-962-3500
  • Fax:
Mailing address:
  • Phone: 931-962-3297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number34800
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: