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General NPI Number Information
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NPI Number | 1063580058
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Entity Type | Individual
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Provider Name | MITZIE RALPH FAIRFIELD NP
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Gender | Female
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Dates
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Enumeration Date | 11/30/2006
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Last Update Date | 10/24/2008
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Provider Practice Location Address
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Address Line | 302 E. STOUGHTON
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City | CHAMPAIGN
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State | IL
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Zip | 61820
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Country | US
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Telephone | 217-359-8022
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Fax |
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Provider Business Mailing Address
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Address Line | 615 COUNTY RD 3400 NORTH
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City | FOOSLAND
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State | IL
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Zip | 61845
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Country | US
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Telephone | 217-897-1096
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LW0102X
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Taxonomy Name | Women's Health Nurse Practitioner
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License Number | 209-000689
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License Number State | IL
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