Provider Demographics
NPI:1861197295
Name:PUCKETT, KENNEDI ELIZABETH (PA)
Entity type:Individual
Prefix:
First Name:KENNEDI
Middle Name:ELIZABETH
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 NW 144TH ST
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-4731
Mailing Address - Country:US
Mailing Address - Phone:918-869-2515
Mailing Address - Fax:
Practice Address - Street 1:1110 N LEE AVE STE 300
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103-2612
Practice Address - Country:US
Practice Address - Phone:405-231-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-04
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OK363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program