Provider Demographics
NPI:1225765720
Name:FAIRWELL, JOSLYN JULIA
Entity Type:Individual
Prefix:
First Name:JOSLYN
Middle Name:JULIA
Last Name:FAIRWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JOSLYN
Other - Middle Name:JULIA
Other - Last Name:FAIRWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12325 SHADOW CREEK PKWY APT 15107
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-7377
Mailing Address - Country:US
Mailing Address - Phone:208-690-1328
Mailing Address - Fax:
Practice Address - Street 1:676 FARM TO MARKET 517 W
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:TX
Practice Address - Zip Code:77539
Practice Address - Country:US
Practice Address - Phone:713-482-4535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPENDING363A00000X
TXPA16055363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant