Provider Demographics
NPI:1750658985
Name:PUCKETT, TYANNA MAGGIE
Entity Type:Individual
Prefix:
First Name:TYANNA
Middle Name:MAGGIE
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 1:414 TENNESSEE ST
Mailing Address - Street 2:SUITE Y
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-8163
Mailing Address - Country:US
Mailing Address - Phone:909-798-9547
Mailing Address - Fax:909-798-4138
Practice Address - Street 1:414 TENNESSEE ST
Practice Address - Street 2:SUITE Y
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-8163
Practice Address - Country:US
Practice Address - Phone:909-798-9547
Practice Address - Fax:909-798-4138
Is Sole Proprietor?:No
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2470A2800XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health InformationAssistant Record Technician