Provider Demographics
NPI:1457830515
Name:FAIRLIE, JENNA
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:FAIRLIE
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 1:181 PARK AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:W SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01089-3365
Mailing Address - Country:US
Mailing Address - Phone:413-796-7499
Mailing Address - Fax:
Practice Address - Street 1:181 PARK AVE STE 5
Practice Address - Street 2:
Practice Address - City:W SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-3365
Practice Address - Country:US
Practice Address - Phone:413-796-7499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2269619367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2269619OtherLICENSE