Provider Demographics
NPI:1588419741
Name:FUSSELL, CHANDLER
Entity type:Individual
Prefix:
First Name:CHANDLER
Middle Name:
Last Name:FUSSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:486 REVELL RD
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-7564
Mailing Address - Country:US
Mailing Address - Phone:731-446-9616
Mailing Address - Fax:
Practice Address - Street 1:1201 BISHOP ST
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:TN
Practice Address - Zip Code:38261-5403
Practice Address - Country:US
Practice Address - Phone:731-285-2410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-22
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN235795163WC0200X
TN36458367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine