MEDICARE: STEPHANIE LYNN PUCKETT PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	21019	FL

General Provider Information

NPI Number	:	1376364182
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE LYNN PUCKETT PTA

Provider Business Mailing Address
First Line	:	3103 E GONZALEZ ST
Second Line	:
City	:	PENSACOLA
State	:	FL
Zip	:	32503-6816
Country	:	US
Telephone Number	:	850-449-1769
Fax Number	:

Provider Business Practice Location Address
First Line	:	760 EAST AVE BLDG 3911
Second Line	:
City	:	PENSACOLA
State	:	FL
Zip	:	32508-5136
Country	:	US
Telephone Number	:	850-505-7345
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2024
Last Update Date	:	10/23/2024

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