Basic Information
| Provider Information | |||||||||
| NPI: | 1265760060 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAIRCLOTH | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 CASTLEMAN LN | ||||||||
| Address2: | |||||||||
| City: | LEEDS | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350943856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2056996215 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2805 DR JOHN HAYNES DR | ||||||||
| Address2: | |||||||||
| City: | PELL CITY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 351251448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663135260 | ||||||||
| FaxNumber: | 2053135245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2009 | ||||||||
| LastUpdateDate: | 12/07/2009 | ||||||||
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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 | 1-030650 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.