Provider Demographics
NPI:1245947332
Name:FAIRFAX ACNE & DERMATOLOGY SERVICES, PC
Entity type:Organization
Organization Name:FAIRFAX ACNE & DERMATOLOGY SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:L
Authorized Official - Last Name:FAIRFAX
Authorized Official - Suffix:
Authorized Official - Credentials:DCNP
Authorized Official - Phone:508-404-3853
Mailing Address - Street 1:1275 WAMPANOAG TRAIL
Mailing Address - Street 2:STE. 6
Mailing Address - City:EAST PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02915-1217
Mailing Address - Country:US
Mailing Address - Phone:508-404-4853
Mailing Address - Fax:
Practice Address - Street 1:1275 WAMPANOAG TRAIL
Practice Address - Street 2:STE. 6
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02915-1217
Practice Address - Country:US
Practice Address - Phone:508-404-4853
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty