Provider Demographics
NPI:1093573776
Name:PUCKHABER, TERESA (APRN)
Entity type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:
Last Name:PUCKHABER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-3111
Mailing Address - Country:US
Mailing Address - Phone:860-485-7573
Mailing Address - Fax:
Practice Address - Street 1:114 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CHESHIRE
Practice Address - State:CT
Practice Address - Zip Code:06410-3111
Practice Address - Country:US
Practice Address - Phone:860-485-7573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-07
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6547363LP0808X, 364SG0600X, 364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology