Healthcare Provider Details

I. General information

NPI: 1336185818
Provider Name (Legal Business Name): MARY C FAIRCHILD FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 01/30/2024
Certification Date: 01/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5008 SW SAND AVE
PALM CITY FL
34990-1395
US

IV. Provider business mailing address

PO BOX 2760
JUPITER FL
33468-2760
US

V. Phone/Fax

Practice location:
  • Phone: 561-748-2889
  • Fax:
Mailing address:
  • Phone: 561-222-2788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11008611
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: