Provider Demographics
NPI:1780169953
Name:FAIRBANKS, LAUREN (NP)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:FAIRBANKS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16775 ADDISON RD STE 200
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-5654
Mailing Address - Country:US
Mailing Address - Phone:972-913-6216
Mailing Address - Fax:972-913-6216
Practice Address - Street 1:3591 MCKINNEY ST STE 400
Practice Address - Street 2:
Practice Address - City:MELISSA
Practice Address - State:TX
Practice Address - Zip Code:75454-9504
Practice Address - Country:US
Practice Address - Phone:972-464-1611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-03
Last Update Date:2021-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP139030363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP139030OtherTEXAS BOARD OF NURSING
TXF09180217OtherTEXAS BOARD OF NURSING