Healthcare Provider Details

I. General information

NPI: 1124440128
Provider Name (Legal Business Name): RUSSELL EDWARD PROFFITT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2014
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1651 GUNBARREL RD STE 102
CHATTANOOGA TN
37421-3289
US

IV. Provider business mailing address

4976 ALPHA LN
HIXSON TN
37343-5470
US

V. Phone/Fax

Practice location:
  • Phone: 423-308-0390
  • Fax: 423-308-0393
Mailing address:
  • Phone: 423-497-5355
  • Fax: 423-308-0281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number18164
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: