Provider Demographics
NPI:1073697090
Name:FAIRLY, REBECCA PATRICIA (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:PATRICIA
Last Name:FAIRLY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MRS
Other - First Name:RBECCA
Other - Middle Name:P
Other - Last Name:FAIRLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNA
Mailing Address - Street 1:109 LAKE HILL PL
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-8237
Mailing Address - Country:US
Mailing Address - Phone:601-259-3217
Mailing Address - Fax:
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:PFS
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-4619
Practice Address - Fax:601-948-4657
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR594792367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00113607Medicaid
MS512I430296Medicare PIN
MS00113607Medicaid