Provider Demographics
NPI:1124440128
Name:PROFFITT, RUSSELL EDWARD (CRNA)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:EDWARD
Last Name:PROFFITT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4976 ALPHA LN
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-5470
Mailing Address - Country:US
Mailing Address - Phone:423-497-5355
Mailing Address - Fax:423-308-0281
Practice Address - Street 1:1651 GUNBARREL RD STE 102
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-3289
Practice Address - Country:US
Practice Address - Phone:423-308-0390
Practice Address - Fax:423-308-0393
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-09
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN18164367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I438345Medicare PIN