Provider Demographics
NPI:1376614099
Name:PUCKETT, MANDY LYNN (RD, MA, CD)
Entity Type:Individual
Prefix:MRS
First Name:MANDY
Middle Name:LYNN
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:RD, MA, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9577 W 400 N
Mailing Address - Street 2:
Mailing Address - City:FARMLAND
Mailing Address - State:IN
Mailing Address - Zip Code:47340-9392
Mailing Address - Country:US
Mailing Address - Phone:765-468-6321
Mailing Address - Fax:
Practice Address - Street 1:2401 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3428
Practice Address - Country:US
Practice Address - Phone:765-747-3345
Practice Address - Fax:765-747-3269
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN296500KMedicare ID - Type UnspecifiedUPLAND HEALTH & DIAG.
IN940810KMedicare Oscar/Certification