Healthcare Provider Details

I. General information

NPI: 1962456061
Provider Name (Legal Business Name): RUSSELL E LITTLE APN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 03/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 E MAIN ST
RUTHERFORD TN
38369-9711
US

IV. Provider business mailing address

PO BOX 370
RUTHERFORD TN
38369-0370
US

V. Phone/Fax

Practice location:
  • Phone: 731-665-7741
  • Fax: 731-665-7750
Mailing address:
  • Phone: 731-665-7741
  • Fax: 731-665-7750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number92256
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: