Provider Demographics
NPI:1851487953
Name:FANKHOUSER, RUSSELL JAMES (AU D CCCA)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:JAMES
Last Name:FANKHOUSER
Suffix:
Gender:M
Credentials:AU D CCCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1185 BULLOCK HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-1113
Mailing Address - Country:US
Mailing Address - Phone:423-878-4171
Mailing Address - Fax:
Practice Address - Street 1:306 SUNSET DRIVE
Practice Address - Street 2:SUITE 103
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604
Practice Address - Country:US
Practice Address - Phone:423-328-9190
Practice Address - Fax:423-328-9189
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNA0000000247231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3967232Medicaid
TN3967232OtherCIGNA MEDICARE
TN3061715OtherBLUE CROSS BLUE SHIELD
TNCA7519OtherRAILROAD MEDICARE