Provider Demographics
NPI:1992040448
Name:PUCKETT, MARY ELLEN (REGISTERED NURSE)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELLEN
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:12501 PROSPERITY DR
Mailing Address - Street 2:100
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-1689
Mailing Address - Country:US
Mailing Address - Phone:301-681-6730
Mailing Address - Fax:301-681-4268
Practice Address - Street 1:12501 PROSPERITY DR
Practice Address - Street 2:100
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-1689
Practice Address - Country:US
Practice Address - Phone:301-681-6730
Practice Address - Fax:301-681-4268
Is Sole Proprietor?:No
Enumeration Date:2012-12-10
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR196603163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse