Provider Demographics
NPI:1093566226
Name:VITALITY MENTAL HEALTH AND WELLNESS PLLC
Entity Type:Organization
Organization Name:VITALITY MENTAL HEALTH AND WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:731-251-3470
Mailing Address - Street 1:1340 DRY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PINSON
Mailing Address - State:TN
Mailing Address - Zip Code:38366-1735
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1385 S HIGHLAND AVE STE B1
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-7547
Practice Address - Country:US
Practice Address - Phone:731-251-3470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-27
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty