Provider Demographics
NPI:1104318666
Name:PUCKETT, KRISTA KAY (APN)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:KAY
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 S YALE AVE
Mailing Address - Street 2:
Mailing Address - City:VILLA PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60181-2868
Mailing Address - Country:US
Mailing Address - Phone:815-871-7897
Mailing Address - Fax:
Practice Address - Street 1:2701 PATRIOT BLVD
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-8039
Practice Address - Country:US
Practice Address - Phone:847-475-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.017748363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily