Provider Demographics
NPI:1972984136
Name:FAIRLEY, JOANNE (NP)
Entity type:Individual
Prefix:MRS
First Name:JOANNE
Middle Name:
Last Name:FAIRLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:PROF
Other - First Name:JOANNA
Other - Middle Name:
Other - Last Name:FAIRLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:7755 CENTER AVE
Mailing Address - Street 2:STE 630
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-9152
Mailing Address - Country:US
Mailing Address - Phone:657-400-5180
Mailing Address - Fax:
Practice Address - Street 1:14116 CUSTOMS BLVD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-5164
Practice Address - Country:US
Practice Address - Phone:601-957-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-13
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR781853363L00000X, 363LG0600X
AZ281478363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology