MEDICARE: TINA MARIE PUCKETT

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	164W00000X	Licensed Practical Nurse	LP049351	AZ

General Provider Information

NPI Number	:	1720568371
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TINA MARIE PUCKETT

Provider Business Mailing Address
First Line	:	1337 NAPOLEON DR
Second Line	:
City	:	OAK HARBOR
State	:	WA
Zip	:	98277-8405
Country	:	US
Telephone Number	:	502-526-2860
Fax Number	:

Provider Business Practice Location Address
First Line	:	1337 NAPOLEON DR
Second Line	:
City	:	OAK HARBOR
State	:	WA
Zip	:	98277-8405
Country	:	US
Telephone Number	:	502-526-2860
Fax Number	:

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

Provider Enumeration Date	:	08/14/2018
Last Update Date	:	08/14/2018

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