Healthcare Provider Details

I. General information

NPI: 1386761062
Provider Name (Legal Business Name): DONNA MARIE FAIRCHILD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 E MAPLE AVE
NEWARK NY
14513-1845
US

IV. Provider business mailing address

224 SCOTT LN
HORSEHEADS NY
14845-1956
US

V. Phone/Fax

Practice location:
  • Phone: 315-331-1700
  • Fax: 315-331-3946
Mailing address:
  • Phone: 607-739-4377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number0041591
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: