Provider Demographics
NPI:1306341672
Name:FAIRBANKS, PATRICIA ANN
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ANN
Last Name:FAIRBANKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 SMITH ST
Mailing Address - Street 2:
Mailing Address - City:POQUOSON
Mailing Address - State:VA
Mailing Address - Zip Code:23662-2029
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12465 WARWICK BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-3041
Practice Address - Country:US
Practice Address - Phone:757-591-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202003979235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist