Provider Demographics
NPI:1366950669
Name:PUCKETT, CHERYL LYNETTE (PTA)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:LYNETTE
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 COUNTY ROAD 193
Mailing Address - Street 2:
Mailing Address - City:MULESHOE
Mailing Address - State:TX
Mailing Address - Zip Code:79347-6288
Mailing Address - Country:US
Mailing Address - Phone:806-946-9555
Mailing Address - Fax:
Practice Address - Street 1:1100 W AVENUE J
Practice Address - Street 2:
Practice Address - City:MULESHOE
Practice Address - State:TX
Practice Address - Zip Code:79347-4424
Practice Address - Country:US
Practice Address - Phone:806-272-7578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-21
Last Update Date:2018-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPTA1454225200000X
TX2128405225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant