Provider Demographics
NPI:1043622129
Name:PUISSANT, REGINA HAFFORD
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:HAFFORD
Last Name:PUISSANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 GOLF COURSE RD
Mailing Address - Street 2:
Mailing Address - City:HAWKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31036-6101
Mailing Address - Country:US
Mailing Address - Phone:478-954-9385
Mailing Address - Fax:478-934-4409
Practice Address - Street 1:52 GOLF COURSE RD
Practice Address - Street 2:
Practice Address - City:HAWKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31036-6101
Practice Address - Country:US
Practice Address - Phone:478-954-9385
Practice Address - Fax:478-934-4409
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-23
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator