Provider Demographics
NPI:1336257336
Name:PUCKETT, TERRY E (CRNA)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:E
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 NEWCOMB AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:KY
Mailing Address - Zip Code:40456-2728
Mailing Address - Country:US
Mailing Address - Phone:606-256-2195
Mailing Address - Fax:606-256-3947
Practice Address - Street 1:145 NEWCOMB AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:KY
Practice Address - Zip Code:40456-2728
Practice Address - Country:US
Practice Address - Phone:606-256-2195
Practice Address - Fax:606-256-3947
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1188A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY74399510Medicaid
KY000000323242OtherANTHEM
KY0880819Medicare ID - Type Unspecified
KYR00557Medicare UPIN
KY0229024Medicare ID - Type Unspecified
KY0666915Medicare ID - Type Unspecified
KYP00111115Medicare ID - Type UnspecifiedRAILROAD MEDICARE