MEDICARE: GEETAWALI PUCKETT LPN

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	305585	NY

General Provider Information

NPI Number	:	1962784272
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GEETAWALI PUCKETT LPN

Provider Business Mailing Address
First Line	:	1020 BEDFORD AVE
Second Line	:	APT 2A
City	:	BROOKLYN
State	:	NY
Zip	:	11205-4834
Country	:	US
Telephone Number	:	347-262-4040
Fax Number	:

Provider Business Practice Location Address
First Line	:	1358 56TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11219-4616
Country	:	US
Telephone Number	:	718-851-7100
Fax Number	:

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

Provider Enumeration Date	:	09/13/2011
Last Update Date	:	09/13/2011

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