Provider Demographics
NPI:1114511250
Name:PUCKETT, RACHEL TIERNEY (PA-C)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:TIERNEY
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 W CIRCLE AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-1516
Mailing Address - Country:US
Mailing Address - Phone:317-354-7903
Mailing Address - Fax:
Practice Address - Street 1:1 E STONE AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29609-5619
Practice Address - Country:US
Practice Address - Phone:864-522-6550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-01
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.006890RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant