Healthcare Provider Details

I. General information

NPI: 1740154210
Provider Name (Legal Business Name): MACY LEA PUCKETT DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2025
Last Update Date: 09/30/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CORNER OF LAMONT STREET AND VETERANS WAY
MOUNTAIN HOME TN
37684
US

IV. Provider business mailing address

430 ROCKHOUSE RD
JOHNSON CITY TN
37601
US

V. Phone/Fax

Practice location:
  • Phone: 423-926-1171
  • Fax:
Mailing address:
  • Phone: 423-926-1171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number16696
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: