Provider Demographics
NPI:1447753520
Name:PUCKETT, MALLORY (CNP)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2718 RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:44601-4810
Mailing Address - Country:US
Mailing Address - Phone:740-381-2826
Mailing Address - Fax:
Practice Address - Street 1:1445 HARRISON AVE NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-2620
Practice Address - Country:US
Practice Address - Phone:330-956-5236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-14
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH022510363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily