Provider Demographics
NPI:1215061973
Name:FAIRFAX, ROXANNE (LMT)
Entity type:Individual
Prefix:MS
First Name:ROXANNE
Middle Name:
Last Name:FAIRFAX
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4529 103RD AVE SE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98205-3106
Mailing Address - Country:US
Mailing Address - Phone:425-319-0848
Mailing Address - Fax:360-794-3184
Practice Address - Street 1:18960 STATE ROUTE 2
Practice Address - Street 2:SUITE 130
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1415
Practice Address - Country:US
Practice Address - Phone:425-319-0848
Practice Address - Fax:360-794-3184
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00019523174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist