1912069428 NPI number — DR. JUANITA J FUSSELL ED.D.

Table of content: DR. JUANITA J FUSSELL ED.D. (NPI 1912069428)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912069428 NPI number — DR. JUANITA J FUSSELL ED.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FUSSELL
Provider First Name:
JUANITA
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
ED.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912069428
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3115 FOWLER MONTGOMERY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COOKEVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38506-6469
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-526-8000
Provider Business Mailing Address Fax Number:
931-526-8000

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
805 N WILLOW AVE
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
COOKEVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38501-1751
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-526-8000
Provider Business Practice Location Address Fax Number:
931-526-8000
Provider Enumeration Date:
12/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  P0000001338 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 103919 . This is a "CIGNA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3094270 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com