Provider Demographics
NPI:1083923262
Name:FAIRCLOTH, PAULINE DEANNIA (NP)
Entity type:Individual
Prefix:
First Name:PAULINE
Middle Name:DEANNIA
Last Name:FAIRCLOTH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 40908
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28309-0908
Mailing Address - Country:US
Mailing Address - Phone:910-615-6448
Mailing Address - Fax:910-615-5070
Practice Address - Street 1:2301 ROBESON ST
Practice Address - Street 2:SUITE 203
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-5640
Practice Address - Country:US
Practice Address - Phone:910-615-3220
Practice Address - Fax:910-486-2170
Is Sole Proprietor?:No
Enumeration Date:2010-10-05
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC164680363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCPENDINGMedicare PIN