Healthcare Provider Details

I. General information

NPI: 1164725396
Provider Name (Legal Business Name): MRS. DIANE D FAFARD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2010
Last Update Date: 12/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 COURT ST SUITE 103
PLYMOUTH MA
02360-7304
US

IV. Provider business mailing address

385 COURT ST SUITE 103
PLYMOUTH MA
02360-7304
US

V. Phone/Fax

Practice location:
  • Phone: 508-830-3444
  • Fax: 508-830-3434
Mailing address:
  • Phone: 508-830-3444
  • Fax: 508-830-3434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: