Provider Demographics
NPI:1750816336
Name:FAIRCLOUGH, JODI-ANN Y (RN)
Entity Type:Individual
Prefix:
First Name:JODI-ANN
Middle Name:Y
Last Name:FAIRCLOUGH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JODI-ANN
Other - Middle Name:Y
Other - Last Name:DENNIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9 FLETCHER RD APT 9B
Mailing Address - Street 2:
Mailing Address - City:MONSEY
Mailing Address - State:NY
Mailing Address - Zip Code:10952-3211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9 FLETCHER RD APT 9B
Practice Address - Street 2:
Practice Address - City:MONSEY
Practice Address - State:NY
Practice Address - Zip Code:10952-3211
Practice Address - Country:US
Practice Address - Phone:845-367-2128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-20
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY728488163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse