Basic Information
| Provider Information | |||||||||
| NPI: | 1972565547 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAIRCHILD | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | JEANETTE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 EAST SHERIDAN RD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329013122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217225200 | ||||||||
| FaxNumber: | 3216373648 | ||||||||
| Practice Location | |||||||||
| Address1: | 2020 COMMERCE DR | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329042335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3219526000 | ||||||||
| FaxNumber: | 3216373648 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2006 | ||||||||
| LastUpdateDate: | 07/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | ARNP299262 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.