Provider Demographics
NPI:1396814695
Name:FAIRALL, LEEANN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:LEEANN
Middle Name:
Last Name:FAIRALL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5358
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37802-5358
Mailing Address - Country:US
Mailing Address - Phone:865-681-9148
Mailing Address - Fax:865-380-2131
Practice Address - Street 1:266 JOULE ST
Practice Address - Street 2:
Practice Address - City:ALCOA
Practice Address - State:TN
Practice Address - Zip Code:37701-2422
Practice Address - Country:US
Practice Address - Phone:865-984-3864
Practice Address - Fax:865-380-2131
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN156363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3679418Medicare ID - Type Unspecified
TNP57318Medicare UPIN