Provider Demographics
NPI:1558193672
Name:PUCKETT, ALVA (CPRS)
Entity type:Individual
Prefix:
First Name:ALVA
Middle Name:
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:CPRS
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 243
Mailing Address - Street 2:
Mailing Address - City:SUGAR GROVE
Mailing Address - State:OH
Mailing Address - Zip Code:43155-0243
Mailing Address - Country:US
Mailing Address - Phone:614-779-5287
Mailing Address - Fax:
Practice Address - Street 1:551 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-3809
Practice Address - Country:US
Practice Address - Phone:614-404-6008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-16
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.005380175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist