1376557421 NPI number — MRS. LAURA SUZANNE FAIRFIELD OTR

Table of content: MRS. LAURA SUZANNE FAIRFIELD OTR (NPI 1376557421)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376557421 NPI number — MRS. LAURA SUZANNE FAIRFIELD OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAIRFIELD
Provider First Name:
LAURA
Provider Middle Name:
SUZANNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROSE
Provider Other First Name:
LAURA
Provider Other Middle Name:
SUZANNE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1376557421
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6342 WINDHAM PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND BLANC
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48439-9127
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-606-8170
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5315 ELLIOTT DR
Provider Second Line Business Practice Location Address:
STE 202
Provider Business Practice Location Address City Name:
YPSILANTI
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48197-8634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-712-0600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  5201004568 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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