Healthcare Provider Details

I. General information

NPI: 1225140320
Provider Name (Legal Business Name): JEAN RUSSELL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH JEAN RUSSELL CRNA

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

919 E CENTRAL AVE SCOTT COUNTY HOSPITAL
LA FOLLETTE TN
37766-2777
US

IV. Provider business mailing address

675 COX HOLLOW RD
KINGSPORT TN
37663-3150
US

V. Phone/Fax

Practice location:
  • Phone: 423-907-1553
  • Fax: 865-777-0910
Mailing address:
  • Phone: 423-349-4314
  • Fax: 423-349-0349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN0000033906
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: