Provider Demographics
NPI:1407217987
Name:FAIRBANKS, TIAHNA E (BA)
Entity Type:Individual
Prefix:
First Name:TIAHNA
Middle Name:E
Last Name:FAIRBANKS
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 AMERICAN LEGION BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-3146
Mailing Address - Country:US
Mailing Address - Phone:208-890-6420
Mailing Address - Fax:
Practice Address - Street 1:2420 AMERICAN LEGION BLVD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-3146
Practice Address - Country:US
Practice Address - Phone:208-890-6420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-11
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist