Provider Demographics
NPI:1588323851
Name:PUCKETT, TRACEY RENEE (PMHNP-BC)
Entity type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:RENEE
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:EPPERSON
Other - Last Name:PUCKETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1340 DRY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PINSON
Mailing Address - State:TN
Mailing Address - Zip Code:38366-1735
Mailing Address - Country:US
Mailing Address - Phone:731-251-3470
Mailing Address - Fax:731-201-5250
Practice Address - Street 1:1385 S HIGHLAND AVE STE B1
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-7547
Practice Address - Country:US
Practice Address - Phone:731-251-3470
Practice Address - Fax:731-201-5250
Is Sole Proprietor?:No
Enumeration Date:2021-12-14
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN30860363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health