Provider Demographics
NPI:1932704467
Name:FAIRCLOTH, AMANDA LEIGH
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEIGH
Last Name:FAIRCLOTH
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 1:4017 E GRANDSTAFF
Mailing Address - Street 2:
Mailing Address - City:CUSHING
Mailing Address - State:OK
Mailing Address - Zip Code:74023-8708
Mailing Address - Country:US
Mailing Address - Phone:904-803-7719
Mailing Address - Fax:
Practice Address - Street 1:4017 E GRANDSTAFF
Practice Address - Street 2:
Practice Address - City:CUSHING
Practice Address - State:OK
Practice Address - Zip Code:74023-8708
Practice Address - Country:US
Practice Address - Phone:904-803-7719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator