Provider Demographics
NPI:1962822817
Name:PUCKETT, ROSHANDA
Entity Type:Individual
Prefix:
First Name:ROSHANDA
Middle Name:
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 1:1309 GREEN VIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-7452
Mailing Address - Country:US
Mailing Address - Phone:678-603-1484
Mailing Address - Fax:
Practice Address - Street 1:1309 GREENVIEW DR
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4048
Practice Address - Country:US
Practice Address - Phone:678-603-1484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-18
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA465422576251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health