Provider Demographics
NPI:1316697444
Name:FAIRBAIRN, CARRIE LEE
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:LEE
Last Name:FAIRBAIRN
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 1:1407 LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:HOQUIAM
Mailing Address - State:WA
Mailing Address - Zip Code:98550-1070
Mailing Address - Country:US
Mailing Address - Phone:503-990-9068
Mailing Address - Fax:
Practice Address - Street 1:300 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:RAYMOND
Practice Address - State:WA
Practice Address - Zip Code:98577-3016
Practice Address - Country:US
Practice Address - Phone:360-942-3040
Practice Address - Fax:360-942-3955
Is Sole Proprietor?:No
Enumeration Date:2022-03-23
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA175T00000X, 172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR7809552OtherDRIVERS LICENSE