Provider Demographics
NPI:1578806220
Name:FAIRLEY, BETTINA RENE' (CNM)
Entity Type:Individual
Prefix:
First Name:BETTINA
Middle Name:RENE'
Last Name:FAIRLEY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 MANCHESTER EXPY STE B001
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-6877
Mailing Address - Country:US
Mailing Address - Phone:706-324-4891
Mailing Address - Fax:
Practice Address - Street 1:2300 MANCHESTER EXPY STE B001
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-6877
Practice Address - Country:US
Practice Address - Phone:706-324-4891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-01
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSCNM1242367A00000X
367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Multi-Specialty