Healthcare Provider Details

I. General information

NPI: 1972984136
Provider Name (Legal Business Name): JOANNE FAIRLEY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JOANNA FAIRLEY PHD

II. Dates (important events)

Enumeration Date: 06/13/2015
Last Update Date: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14116 CUSTOMS BLVD
GULFPORT MS
39503-5164
US

IV. Provider business mailing address

7755 CENTER AVE STE 630
HUNTINGTON BEACH CA
92647-9152
US

V. Phone/Fax

Practice location:
  • Phone: 601-957-6300
  • Fax:
Mailing address:
  • Phone: 657-400-5180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR781853
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberR781853
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number281478
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: