Healthcare Provider Details

I. General information

NPI: 1164336392
Provider Name (Legal Business Name): KRYSTAL PUCKETT RN
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8600 SHERIDAN RD
KENOSHA WI
53143-6506
US

IV. Provider business mailing address

1404 71ST DR
UNION GROVE WI
53182-1626
US

V. Phone/Fax

Practice location:
  • Phone: 262-771-9275
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number172877-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: