Provider Demographics
NPI:1598249765
Name:PUCKETT, VICTORIA DANIELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:DANIELLE
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:DANIELLE
Other - Last Name:KISSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1001 BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44504-1003
Mailing Address - Country:US
Mailing Address - Phone:330-747-6446
Mailing Address - Fax:330-747-6843
Practice Address - Street 1:1001 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44504-1003
Practice Address - Country:US
Practice Address - Phone:330-747-6446
Practice Address - Fax:330-747-6843
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2192363AS0400X
OH50.006282RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical