Healthcare Provider Details

I. General information

NPI: 1902712888
Provider Name (Legal Business Name): EBONIE FAIRFAX
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 72ND ST SE
GRAND RAPIDS MI
49548-7374
US

IV. Provider business mailing address

451 72ND ST SE
GRAND RAPIDS MI
49548-7374
US

V. Phone/Fax

Practice location:
  • Phone: 810-449-0726
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: