Provider Demographics
NPI:1033810221
Name:FAIRCLOTH, KILEY
Entity Type:Individual
Prefix:
First Name:KILEY
Middle Name:
Last Name:FAIRCLOTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4019 SID HENDRY RD
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32347-9304
Mailing Address - Country:US
Mailing Address - Phone:850-843-3898
Mailing Address - Fax:
Practice Address - Street 1:4019 SID HENDRY RD
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:FL
Practice Address - Zip Code:32347-9304
Practice Address - Country:US
Practice Address - Phone:850-843-3898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-14
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11025175363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily