Healthcare Provider Details

I. General information

NPI: 1376526392
Provider Name (Legal Business Name): MICHELLE GRACE PUZDRAKIEWICZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 WOODLAWN AVE
DYERSBURG TN
38024-2028
US

IV. Provider business mailing address

1804 HIGHWAY 45 BYP STE 604
JACKSON TN
38305-4403
US

V. Phone/Fax

Practice location:
  • Phone: 731-287-4500
  • Fax: 731-287-4804
Mailing address:
  • Phone: 731-660-7971
  • Fax: 731-660-8739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number308800
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number42447
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: