Basic Information
| Provider Information | |||||||||
| NPI: | 1255470928 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PUCKETT | ||||||||
| FirstName: | MARIAN | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 235 HANNIS RD | ||||||||
| Address2: | |||||||||
| City: | BOLIVAR | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380084107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316582500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 789 TENNESSEE ST | ||||||||
| Address2: | |||||||||
| City: | BOLIVAR | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380082441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316582206 | ||||||||
| FaxNumber: | 7316592061 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 0000001854 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.