Provider Demographics
NPI:1023809621
Name:FAIRBANKS, SHELLEY MARIE
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:MARIE
Last Name:FAIRBANKS
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:PO BOX 82
Mailing Address - Street 2:
Mailing Address - City:GREENLAND
Mailing Address - State:AR
Mailing Address - Zip Code:72737-0082
Mailing Address - Country:US
Mailing Address - Phone:479-236-7179
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 82
Practice Address - Street 2:
Practice Address - City:GREENLAND
Practice Address - State:AR
Practice Address - Zip Code:72737-0082
Practice Address - Country:US
Practice Address - Phone:479-236-7179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-14
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty