Provider Demographics
NPI:1184314775
Name:FAIRFAX, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:FAIRFAX
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 1:431 56TH ST # 1
Mailing Address - Street 2:
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-2133
Mailing Address - Country:US
Mailing Address - Phone:646-905-9558
Mailing Address - Fax:
Practice Address - Street 1:431 56TH ST # 1
Practice Address - Street 2:
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093-2133
Practice Address - Country:US
Practice Address - Phone:646-905-9558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NH19618000374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide