Provider Demographics
NPI:1114511250
Name:PUCKETT, RACHEL TIERNEY (PA-C)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:TIERNEY
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6294 EBERSTARK DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-5076
Mailing Address - Country:US
Mailing Address - Phone:317-354-7903
Mailing Address - Fax:
Practice Address - Street 1:699 HARRISBURG PIKE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43223-2141
Practice Address - Country:US
Practice Address - Phone:614-274-2077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-01
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.006890RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant