Healthcare Provider Details

I. General information

NPI: 1720920598
Provider Name (Legal Business Name): MINA RAE FAIRALL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2026
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 N UNIVERSITY AVE
ANN ARBOR MI
48109-1048
US

IV. Provider business mailing address

540 THOMPSON ST MUNGER GRADUATE RESIDENCES 1033
ANN ARBOR MI
48104-2414
US

V. Phone/Fax

Practice location:
  • Phone: 734-764-1817
  • Fax:
Mailing address:
  • Phone: 323-401-0362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: