Provider Demographics
NPI:1952767212
Name:FAIRCLOTH, ADRIENNE J (ATC)
Entity type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:J
Last Name:FAIRCLOTH
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9709 49TH PL
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20740-1433
Mailing Address - Country:US
Mailing Address - Phone:757-831-5554
Mailing Address - Fax:
Practice Address - Street 1:4313 MADISON ST
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20781-1625
Practice Address - Country:US
Practice Address - Phone:240-764-2533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-01
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00007842255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer