Provider Demographics
NPI:1811754658
Name:FAIRCLOTH, REBECCA ANN
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANN
Last Name:FAIRCLOTH
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 1:598 BERNICE AVE
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25405-4178
Mailing Address - Country:US
Mailing Address - Phone:304-616-7924
Mailing Address - Fax:
Practice Address - Street 1:598 BERNICE AVE
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25405-4178
Practice Address - Country:US
Practice Address - Phone:304-616-7924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant