Provider Demographics
NPI:1053800789
Name:PUCKETT, TEAGAN IONA
Entity type:Individual
Prefix:
First Name:TEAGAN
Middle Name:IONA
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:PO BOX 132
Mailing Address - Street 2:
Mailing Address - City:SNELLING
Mailing Address - State:CA
Mailing Address - Zip Code:95369-0132
Mailing Address - Country:US
Mailing Address - Phone:209-777-7847
Mailing Address - Fax:
Practice Address - Street 1:5241 N MAPLE AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93740-0001
Practice Address - Country:US
Practice Address - Phone:559-278-2016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer