Provider Demographics
NPI:1457876591
Name:FAIRCLOTH, ALLAN MARCOS (DNP, PMHNP-BC, RN)
Entity Type:Individual
Prefix:DR
First Name:ALLAN
Middle Name:MARCOS
Last Name:FAIRCLOTH
Suffix:
Gender:M
Credentials:DNP, PMHNP-BC, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 KING ST APT 1E
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-1699
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1901 ADAMS FARM PKWY
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-6338
Practice Address - Country:US
Practice Address - Phone:336-722-7266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-10
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC271994163W00000X
NC5014648363LP0808X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health