Provider Demographics
NPI:1073205753
Name:PUCKETT, KATIE ANN (APRN)
Entity Type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:ANN
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1159 WATERSCAPE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROYSE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:75189-2104
Mailing Address - Country:US
Mailing Address - Phone:325-201-6165
Mailing Address - Fax:
Practice Address - Street 1:6435 S FM 549 STE 201
Practice Address - Street 2:
Practice Address - City:HEATH
Practice Address - State:TX
Practice Address - Zip Code:75032-6225
Practice Address - Country:US
Practice Address - Phone:214-771-3712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1121095363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics