Provider Demographics
NPI:1215166384
Name:RUSSELL, JOY DANAE (DPM)
Entity type:Individual
Prefix:
First Name:JOY
Middle Name:DANAE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 BRAINERD RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37411-4016
Mailing Address - Country:US
Mailing Address - Phone:423-521-8605
Mailing Address - Fax:423-521-8607
Practice Address - Street 1:5701 BRAINERD RD
Practice Address - Street 2:SUITE 111
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37411-4016
Practice Address - Country:US
Practice Address - Phone:423-521-8605
Practice Address - Fax:423-521-8607
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-09
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN704213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN9862600OtherAETNA
TN8069587OtherCIGNA
TN1520824Medicaid
TN1147592OtherUSA MANAGED CARE
TN4282079OtherBCBS TN
TN1520824Medicaid