Provider Demographics
NPI:1558844662
Name:PUCKETT, ROBIN RENEE
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:RENEE
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 1:6460 HARRISON AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45247-7958
Mailing Address - Country:US
Mailing Address - Phone:513-941-4999
Mailing Address - Fax:513-694-0168
Practice Address - Street 1:1130 GARBRY RD
Practice Address - Street 2:
Practice Address - City:PIQUA
Practice Address - State:OH
Practice Address - Zip Code:45356-8217
Practice Address - Country:US
Practice Address - Phone:513-941-4999
Practice Address - Fax:513-694-0168
Is Sole Proprietor?:No
Enumeration Date:2018-09-13
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.153665.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0315247Medicaid