Basic Information
Provider Information | |||||||||
NPI: | 1376526392 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PUZDRAKIEWICZ | ||||||||
FirstName: | MICHELLE | ||||||||
MiddleName: | GRACE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1804 HIGHWAY 45 BYP STE 604 | ||||||||
Address2: |   | ||||||||
City: | JACKSON | ||||||||
State: | TN | ||||||||
PostalCode: | 383054403 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7316607971 | ||||||||
FaxNumber: | 7316608739 | ||||||||
Practice Location | |||||||||
Address1: | 1700 WOODLAWN AVE | ||||||||
Address2: |   | ||||||||
City: | DYERSBURG | ||||||||
State: | TN | ||||||||
PostalCode: | 380242028 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7312874500 | ||||||||
FaxNumber: | 7312874804 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/23/2005 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 308800 | LA | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208000000X | 42447 | TN | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 1510509 | 05 | TN |   | MEDICAID |