Provider Demographics
NPI:1639353261
Name:PUCKETT, DANNIELLE ROSE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:DANNIELLE
Middle Name:ROSE
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MRS
Other - First Name:DANNIELLE
Other - Middle Name:ROSE
Other - Last Name:HUMPHREY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:301 MARGIE DR
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-7818
Mailing Address - Country:US
Mailing Address - Phone:478-953-5800
Mailing Address - Fax:478-953-5800
Practice Address - Street 1:301 MARGIE DR
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-7818
Practice Address - Country:US
Practice Address - Phone:478-953-5800
Practice Address - Fax:478-953-5800
Is Sole Proprietor?:No
Enumeration Date:2007-12-18
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001447225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant