Healthcare Provider Details

I. General information

NPI: 1215178744
Provider Name (Legal Business Name): MICHELE L PUCKETT CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2009
Last Update Date: 03/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2011 GALLATIN ST SW
HUNTSVILLE AL
35801-4510
US

IV. Provider business mailing address

2011 GALLATIN ST SW
HUNTSVILLE AL
35801-4510
US

V. Phone/Fax

Practice location:
  • Phone: 256-382-1603
  • Fax: 256-382-1607
Mailing address:
  • Phone: 256-382-1603
  • Fax: 256-382-1607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1-058470
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: