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General NPI Number Information
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NPI Number | 1720272834
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Entity Type | Organization
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Legal Business Name | WILLOW FAMILY MEDICINE, LLC
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Dates
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Enumeration Date | 08/31/2007
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Last Update Date | 02/07/2008
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Provider Practice Location Address
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Address Line | 304 TEACO RD SUITE A
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City | KENNETT
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State | MO
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Zip | 63857-3266
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Country | US
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Telephone | 573-888-0303
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Fax | 573-888-0304
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Provider Business Mailing Address
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Address Line | 304 TEACO RD SUITE A
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City | KENNETT
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State | MO
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Zip | 63857-3266
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Country | US
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Telephone | 573-888-0303
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Fax | 573-888-0304
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Authorized Official
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Title or Position | PHYSICIAN, OWNER
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Name | JENNIFER RENEE PUCKETT
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Credential | DO
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Telephone | 573-888-0303
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 2006013170
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number | 2006013170
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License Number State | MO
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