Provider Demographics
NPI:1508491143
Name:CAUDILL, MICHELL E (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELL
Middle Name:E
Last Name:CAUDILL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 RIDGEWATER WAY
Mailing Address - Street 2:
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-5723
Mailing Address - Country:US
Mailing Address - Phone:615-521-9097
Mailing Address - Fax:
Practice Address - Street 1:234 RIDGEWATER WAY
Practice Address - Street 2:
Practice Address - City:MOUNT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-5723
Practice Address - Country:US
Practice Address - Phone:615-521-9097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-04
Last Update Date:2022-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA547363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant