Healthcare Provider Details

I. General information

NPI: 1538105135
Provider Name (Legal Business Name): CLARISSE FAIRBANKS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 06/25/2024
Certification Date: 06/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 JUNIPER LN
WEST HARTFORD CT
06117-1126
US

IV. Provider business mailing address

18 JUNIPER LN
WEST HARTFORD CT
06117-1126
US

V. Phone/Fax

Practice location:
  • Phone: 860-414-4787
  • Fax:
Mailing address:
  • Phone: 860-414-4787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number003066
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: