Provider Demographics
NPI:1689285249
Name:PUCKETT FAMILY MEDICAL CLINIC
Entity Type:Organization
Organization Name:PUCKETT FAMILY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASHELY
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHIVERS
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:601-824-9490
Mailing Address - Street 1:PO BOX 580
Mailing Address - Street 2:
Mailing Address - City:PUCKETT
Mailing Address - State:MS
Mailing Address - Zip Code:39151-0580
Mailing Address - Country:US
Mailing Address - Phone:601-824-9490
Mailing Address - Fax:601-824-5855
Practice Address - Street 1:6455 HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-7536
Practice Address - Country:US
Practice Address - Phone:601-824-9490
Practice Address - Fax:601-824-5855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-16
Last Update Date:2020-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty