Healthcare Provider Details

I. General information

NPI: 1538873633
Provider Name (Legal Business Name): SARAH MICHELLE PUCKETT FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2023
Last Update Date: 04/05/2024
Certification Date: 04/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HAIRPIN DR
EDWARDSVILLE IL
62026-0001
US

IV. Provider business mailing address

1 HAIRPIN DR
EDWARDSVILLE IL
62026-0001
US

V. Phone/Fax

Practice location:
  • Phone: 618-650-3956
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209028213
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: