Provider Demographics
NPI:1073383022
Name:FAIRCHILD, LIBBIE ANNE
Entity Type:Individual
Prefix:
First Name:LIBBIE
Middle Name:ANNE
Last Name:FAIRCHILD
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 1:10334 HAZY GLEN DR
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-7929
Mailing Address - Country:US
Mailing Address - Phone:808-931-0274
Mailing Address - Fax:
Practice Address - Street 1:3307 CALDWELL BLVD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-6402
Practice Address - Country:US
Practice Address - Phone:208-465-4833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health