Provider Demographics
NPI:1205371325
Name:PUCKETT, RHONDA KIM
Entity Type:Individual
Prefix:
First Name:RHONDA
Middle Name:KIM
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RHONDA
Other - Middle Name:KIM
Other - Last Name:EARWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 80883
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30608-0883
Mailing Address - Country:US
Mailing Address - Phone:706-549-8114
Mailing Address - Fax:
Practice Address - Street 1:18 RIVERBEND DR SW STE 120
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161
Practice Address - Country:US
Practice Address - Phone:706-378-1202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-28
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN077416363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003200186Medicaid