Provider Demographics
NPI:1518562669
Name:PUCKETT, BRANDE (LPTA)
Entity Type:Individual
Prefix:
First Name:BRANDE
Middle Name:
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:BRANDE
Other - Middle Name:
Other - Last Name:KLUGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7045 HOPEWELL RD E
Mailing Address - Street 2:
Mailing Address - City:MUSELLA
Mailing Address - State:GA
Mailing Address - Zip Code:31066-3421
Mailing Address - Country:US
Mailing Address - Phone:478-951-1937
Mailing Address - Fax:
Practice Address - Street 1:3356 VINEVILLE AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-2328
Practice Address - Country:US
Practice Address - Phone:478-476-9642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001605225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant