Provider Demographics
NPI:1053818922
Name:PECK, MICHELLE BAISDEN
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:BAISDEN
Last Name:PECK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7714 CONNER RD STE 101
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37849-3559
Mailing Address - Country:US
Mailing Address - Phone:865-212-6441
Mailing Address - Fax:865-212-6446
Practice Address - Street 1:7714 CONNER RD STE 101
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:TN
Practice Address - Zip Code:37849-3559
Practice Address - Country:US
Practice Address - Phone:865-212-6441
Practice Address - Fax:865-212-6446
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN23943363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics