Provider Demographics
NPI:1225140320
Name:RUSSELL, JEAN (CRNA)
Entity Type:Individual
Prefix:MS
First Name:JEAN
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:JEAN
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:675 COX HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37663-3150
Mailing Address - Country:US
Mailing Address - Phone:423-349-4314
Mailing Address - Fax:423-349-0349
Practice Address - Street 1:919 E CENTRAL AVE
Practice Address - Street 2:SCOTT COUNTY HOSPITAL
Practice Address - City:LA FOLLETTE
Practice Address - State:TN
Practice Address - Zip Code:37766-2777
Practice Address - Country:US
Practice Address - Phone:423-907-1553
Practice Address - Fax:865-777-0910
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000033906367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3608552Medicaid
TN3608552Medicare ID - Type Unspecified