Provider Demographics
NPI:1912201039
Name:FAIRBANKS, TARYN E (CRNA)
Entity Type:Individual
Prefix:
First Name:TARYN
Middle Name:E
Last Name:FAIRBANKS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TARYN
Other - Middle Name:E
Other - Last Name:HICKMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3549
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-0549
Mailing Address - Country:US
Mailing Address - Phone:423-698-3309
Mailing Address - Fax:423-624-6355
Practice Address - Street 1:2341 MCCALLIE AVE
Practice Address - Street 2:SUITE 402
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-3239
Practice Address - Country:US
Practice Address - Phone:423-698-3309
Practice Address - Fax:423-624-6355
Is Sole Proprietor?:No
Enumeration Date:2011-01-04
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN148026367500000X
TNAPN15431367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4284390OtherBLUE CROSS BLUE SHIELD OF TN
TN1522298Medicaid
P00904219OtherRAILROAD MEDICARE
TN4284390OtherBLUE CROSS BLUE SHIELD OF TN