Healthcare Provider Details

I. General information

NPI: 1114138872
Provider Name (Legal Business Name): TRACY D. FAIRBAIRN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRACY D FARMER

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 05/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 E CHEROKEE ST
SPRINGFIELD MO
65804-2203
US

IV. Provider business mailing address

PO BOX 2580
SPRINGFIELD MO
65801-2580
US

V. Phone/Fax

Practice location:
  • Phone: 417-820-2829
  • Fax: 417-820-8852
Mailing address:
  • Phone: 417-829-4620
  • Fax: 417-829-4316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2000165088
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: