Provider Demographics
NPI:1962720037
Name:PUCKETT, MAUREEN MINTER (NNP)
Entity type:Individual
Prefix:
First Name:MAUREEN
Middle Name:MINTER
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 RIVERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24503
Mailing Address - Country:US
Mailing Address - Phone:434-200-5621
Mailing Address - Fax:
Practice Address - Street 1:3300 RIVERMONT AVE
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24503
Practice Address - Country:US
Practice Address - Phone:434-200-5621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-13
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001194391163W00000X
VA0024168397363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No163W00000XNursing Service ProvidersRegistered Nurse