Provider Demographics
NPI:1386761062
Name:FAIRCHILD, DONNA MARIE
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:MARIE
Last Name:FAIRCHILD
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 1:224 SCOTT LN
Mailing Address - Street 2:
Mailing Address - City:HORSEHEADS
Mailing Address - State:NY
Mailing Address - Zip Code:14845-1956
Mailing Address - Country:US
Mailing Address - Phone:607-739-4377
Mailing Address - Fax:
Practice Address - Street 1:703 E MAPLE AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513-1845
Practice Address - Country:US
Practice Address - Phone:315-331-1700
Practice Address - Fax:315-331-3946
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0041591133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist