Provider Demographics
NPI:1578172854
Name:CHAVIS, JUSTIN RYAN (RN)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:RYAN
Last Name:CHAVIS
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1149 E MAIN ST APT 302
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37408-1631
Mailing Address - Country:US
Mailing Address - Phone:803-743-6024
Mailing Address - Fax:
Practice Address - Street 1:1 ELLIOT WAY STE 200
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03103-3502
Practice Address - Country:US
Practice Address - Phone:603-663-2315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN205913163W00000X
NH132452367500000X
NH083681-23367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse