Provider Demographics
NPI:1841438439
Name:FAIRCLOTH, DEBORAH
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
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:PO BOX 157
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:NC
Mailing Address - Zip Code:28398-0157
Mailing Address - Country:US
Mailing Address - Phone:910-290-0291
Mailing Address - Fax:
Practice Address - Street 1:851 OUTLAW RD
Practice Address - Street 2:
Practice Address - City:DUDLEY
Practice Address - State:NC
Practice Address - Zip Code:28333-8145
Practice Address - Country:US
Practice Address - Phone:910-290-0291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-04
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8302553Medicaid