Provider Demographics
NPI:1144794793
Name:FAIRBANKS, MICHAELA ASHLYN (ATC,LAT)
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:ASHLYN
Last Name:FAIRBANKS
Suffix:
Gender:F
Credentials:ATC,LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44711 COUNTY ROAD 18
Mailing Address - Street 2:
Mailing Address - City:DEER RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:56636-2148
Mailing Address - Country:US
Mailing Address - Phone:218-368-7931
Mailing Address - Fax:
Practice Address - Street 1:44711 COUNTY ROAD 18
Practice Address - Street 2:
Practice Address - City:DEER RIVER
Practice Address - State:MN
Practice Address - Zip Code:56636-2148
Practice Address - Country:US
Practice Address - Phone:218-368-7931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer