Provider Demographics
NPI:1073124442
Name:PUCKETT, TYRESHA LANEE (LVN)
Entity Type:Individual
Prefix:
First Name:TYRESHA
Middle Name:LANEE
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5373
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90805-0373
Mailing Address - Country:US
Mailing Address - Phone:562-499-9584
Mailing Address - Fax:
Practice Address - Street 1:8207 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:PICO RIVERA
Practice Address - State:CA
Practice Address - Zip Code:90660-2521
Practice Address - Country:US
Practice Address - Phone:562-695-0737
Practice Address - Fax:562-695-0414
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-11
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA711823164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Single Specialty