Provider Demographics
NPI:1306550090
Name:FAIRCLOTH, DELLAANN (RN)
Entity type:Individual
Prefix:
First Name:DELLAANN
Middle Name:
Last Name:FAIRCLOTH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 231
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31310-0231
Mailing Address - Country:US
Mailing Address - Phone:912-876-2173
Mailing Address - Fax:912-876-2637
Practice Address - Street 1:1113 E OGLETHORPE HWY
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-1200
Practice Address - Country:US
Practice Address - Phone:912-876-2173
Practice Address - Fax:912-876-2637
Is Sole Proprietor?:No
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN291867163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health