Provider Demographics
NPI:1942516166
Name:FAIRCLOTH, JIMANN MARIE (LPN)
Entity Type:Individual
Prefix:
First Name:JIMANN
Middle Name:MARIE
Last Name:FAIRCLOTH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2419 NW 3RD ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73107-6937
Mailing Address - Country:US
Mailing Address - Phone:405-248-6943
Mailing Address - Fax:
Practice Address - Street 1:1215 NW 25TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73106-5629
Practice Address - Country:US
Practice Address - Phone:405-525-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-25
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKL0056198164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse