Provider Demographics
NPI:1023016953
Name:FAIRFAX, DIANA L (NP)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:L
Last Name:FAIRFAX
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 E. WASHINGTON STREET
Mailing Address - Street 2:
Mailing Address - City:N. ATTLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02760
Mailing Address - Country:US
Mailing Address - Phone:508-699-7546
Mailing Address - Fax:508-699-7570
Practice Address - Street 1:153 E. WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:N. ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02760
Practice Address - Country:US
Practice Address - Phone:508-699-7546
Practice Address - Fax:508-699-7570
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA161165363L00000X
MARN161165363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP048501Medicare PIN
MANP048501Medicare UPIN