Provider Demographics
NPI:1235400383
Name:NANCY A. PUCKETT
Entity Type:Organization
Organization Name:NANCY A. PUCKETT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LMHP, CPC
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:PUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:308-728-9979
Mailing Address - Street 1:PO BOX 226
Mailing Address - Street 2:
Mailing Address - City:ORD
Mailing Address - State:NE
Mailing Address - Zip Code:68862-0226
Mailing Address - Country:US
Mailing Address - Phone:308-728-9979
Mailing Address - Fax:308-728-9980
Practice Address - Street 1:100 N 15TH ST
Practice Address - Street 2:
Practice Address - City:ORD
Practice Address - State:NE
Practice Address - Zip Code:68862-1458
Practice Address - Country:US
Practice Address - Phone:308-728-9979
Practice Address - Fax:308-728-9980
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NANCY A. PUCKETT, LMHP,CPC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-01-21
Last Update Date:2012-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2947251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025457200Medicaid