Provider Demographics
NPI:1043497670
Name:FAIRLEY, KEVIN M (APN-BC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:FAIRLEY
Suffix:
Gender:M
Credentials:APN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 GEORGIAN RD
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:MA
Mailing Address - Zip Code:02493-2110
Mailing Address - Country:US
Mailing Address - Phone:781-642-8618
Mailing Address - Fax:781-398-8341
Practice Address - Street 1:45 GEORGIAN RD
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:MA
Practice Address - Zip Code:02493-2110
Practice Address - Country:US
Practice Address - Phone:781-642-8618
Practice Address - Fax:781-398-8341
Is Sole Proprietor?:No
Enumeration Date:2008-01-25
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA254740363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health