Provider Demographics
NPI:1538105135
Name:FAIRBANKS, CLARISSE (APRN)
Entity type:Individual
Prefix:
First Name:CLARISSE
Middle Name:
Last Name:FAIRBANKS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 JUNIPER LN
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06117-1126
Mailing Address - Country:US
Mailing Address - Phone:860-414-4787
Mailing Address - Fax:
Practice Address - Street 1:18 JUNIPER LN
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06117-1126
Practice Address - Country:US
Practice Address - Phone:860-414-4787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-21
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003066364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult