Provider Demographics
NPI:1306391370
Name:FAIRBANKS, MIKALA
Entity Type:Individual
Prefix:
First Name:MIKALA
Middle Name:
Last Name:FAIRBANKS
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 1:638 N 450 W
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-3794
Mailing Address - Country:US
Mailing Address - Phone:801-717-6027
Mailing Address - Fax:
Practice Address - Street 1:638 N 450 W
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-3794
Practice Address - Country:US
Practice Address - Phone:801-373-4760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-19
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT178234323171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator