Provider Demographics
NPI:1386473403
Name:PUCKETT, JOLIE ALEXIS (NP)
Entity type:Individual
Prefix:
First Name:JOLIE
Middle Name:ALEXIS
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:253 CHUBBTOWN RD
Mailing Address - Street 2:
Mailing Address - City:CEDARTOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30125-4330
Mailing Address - Country:US
Mailing Address - Phone:678-988-6179
Mailing Address - Fax:
Practice Address - Street 1:304 TURNER MCCALL BLVD SW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-5621
Practice Address - Country:US
Practice Address - Phone:706-509-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-29
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN268423363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care