Provider Demographics
NPI:1528197126
Name:FAIRBANKS, MARY E (MS, RN, PHN)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:E
Last Name:FAIRBANKS
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Gender:F
Credentials:MS, RN, PHN
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Mailing Address - Street 1:3225 DORAL DR NE
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-9063
Mailing Address - Country:US
Mailing Address - Phone:218-444-0488
Mailing Address - Fax:218-444-0498
Practice Address - Street 1:522 MINNESOTA AVE NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-3062
Practice Address - Country:US
Practice Address - Phone:218-444-0488
Practice Address - Fax:218-444-0498
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MNR122592-3163WC1500X, 163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Not Answered163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice