Provider Demographics
NPI:1417122540
Name:FAIRCLOTH, AMY L (PT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:FAIRCLOTH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:739 CHAPPELL DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27606-3215
Mailing Address - Country:US
Mailing Address - Phone:919-832-3909
Mailing Address - Fax:919-863-2021
Practice Address - Street 1:739 CHAPPELL DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27606-3215
Practice Address - Country:US
Practice Address - Phone:919-832-3909
Practice Address - Fax:919-863-2021
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC93422251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics