Basic Information
| Provider Information | |||||||||
| NPI: | 1083923262 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAIRCLOTH | ||||||||
| FirstName: | PAULINE | ||||||||
| MiddleName: | DEANNIA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40908 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283090908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106156448 | ||||||||
| FaxNumber: | 9106155070 | ||||||||
| Practice Location | |||||||||
| Address1: | 2301 ROBESON ST | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283055640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106153220 | ||||||||
| FaxNumber: | 9104862170 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2010 | ||||||||
| LastUpdateDate: | 06/19/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 164680 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2200X | 164680 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.