Provider Demographics
NPI:1184376527
Name:PUCKETT, LAURA KATHERINE (RD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:KATHERINE
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:KATHERINE
Other - Last Name:HENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-2965
Mailing Address - Country:US
Mailing Address - Phone:254-724-2111
Mailing Address - Fax:
Practice Address - Street 1:2401 S 31ST ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76508-0001
Practice Address - Country:US
Practice Address - Phone:254-724-2397
Practice Address - Fax:254-724-5473
Is Sole Proprietor?:No
Enumeration Date:2022-01-26
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT86207133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered