MEDICARE: ELEANOR H PUCKETT ARNP

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	RN1028841	KY

General Provider Information

NPI Number	:	1578513776
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELEANOR H PUCKETT ARNP

Provider Business Mailing Address
First Line	:	10510 LAGRANGE RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40223-1277
Country	:	US
Telephone Number	:	502-253-7194
Fax Number	:

Provider Business Practice Location Address
First Line	:	10510 LAGRANGE RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40223-1277
Country	:	US
Telephone Number	:	502-253-7194
Fax Number	:

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

Provider Enumeration Date	:	05/11/2006
Last Update Date	:	07/08/2007

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