Provider Demographics
NPI:1427333160
Name:FAIRCLOUGH, PAULETTE EVANGELLE
Entity type:Individual
Prefix:
First Name:PAULETTE
Middle Name:EVANGELLE
Last Name:FAIRCLOUGH
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 1:652 CHRISTIE STREET
Mailing Address - Street 2:
Mailing Address - City:SOUTH HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11580-7212
Mailing Address - Country:US
Mailing Address - Phone:516-901-7640
Mailing Address - Fax:
Practice Address - Street 1:800 FRONT ST
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550
Practice Address - Country:US
Practice Address - Phone:516-705-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-13
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY303620-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse