Provider Demographics
NPI:1225549728
Name:PUCKETT, TANISHA DANIELLE
Entity Type:Individual
Prefix:
First Name:TANISHA
Middle Name:DANIELLE
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1571 EDGEWATER LN
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-1547
Mailing Address - Country:US
Mailing Address - Phone:912-492-2233
Mailing Address - Fax:
Practice Address - Street 1:913C TINY TOWN RD STE 114
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042-4603
Practice Address - Country:US
Practice Address - Phone:912-492-2233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-24
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management