Provider Demographics
NPI:1790324911
Name:FAIRWELL, TAMIKA
Entity Type:Individual
Prefix:
First Name:TAMIKA
Middle Name:
Last Name:FAIRWELL
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 1:83 PELHAM DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31903-4115
Mailing Address - Country:US
Mailing Address - Phone:706-332-5097
Mailing Address - Fax:
Practice Address - Street 1:83 PELHAM DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31903-4115
Practice Address - Country:US
Practice Address - Phone:706-332-5097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACN0028837279376K00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No376K00000XNursing Service Related ProvidersNurse's Aide