Provider Demographics
NPI:1114629037
Name:PUCKETT, AMANDA (CRNP)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2720 CARSINS RUN RD
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:MD
Mailing Address - Zip Code:21001-1516
Mailing Address - Country:US
Mailing Address - Phone:443-356-1922
Mailing Address - Fax:
Practice Address - Street 1:2720 CARSINS RUN RD
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:MD
Practice Address - Zip Code:21001-1516
Practice Address - Country:US
Practice Address - Phone:443-356-1922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-22
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR232943363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health