Provider Demographics
NPI: | 1083923262 |
---|---|
Name: | FAIRCLOTH, PAULINE DEANNIA (NP) |
Entity Type: | Individual |
Prefix: | |
First Name: | PAULINE |
Middle Name: | DEANNIA |
Last Name: | FAIRCLOTH |
Suffix: | |
Gender: | F |
Credentials: | NP |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | PO BOX 40908 |
Mailing Address - Street 2: | |
Mailing Address - City: | FAYETTEVILLE |
Mailing Address - State: | NC |
Mailing Address - Zip Code: | 28309-0908 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 910-615-6448 |
Mailing Address - Fax: | 910-615-5070 |
Practice Address - Street 1: | 2301 ROBESON ST |
Practice Address - Street 2: | SUITE 203 |
Practice Address - City: | FAYETTEVILLE |
Practice Address - State: | NC |
Practice Address - Zip Code: | 28305-5640 |
Practice Address - Country: | US |
Practice Address - Phone: | 910-615-3220 |
Practice Address - Fax: | 910-486-2170 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2010-10-05 |
Last Update Date: | 2019-06-19 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NC | 164680 | 363L00000X, 363LA2200X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LA2200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NC | PENDING | Medicare PIN |