Provider Demographics
NPI:1548357320
Name:FAIRBANKS, BELINDA DIANE
Entity type:Individual
Prefix:
First Name:BELINDA
Middle Name:DIANE
Last Name:FAIRBANKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1481 E 1300 S
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46901-7622
Mailing Address - Country:US
Mailing Address - Phone:654-325-2967
Mailing Address - Fax:765-689-7257
Practice Address - Street 1:1481 E 1300 S
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-7622
Practice Address - Country:US
Practice Address - Phone:765-432-5296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN17001101A237700000X, 237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0000000392105OtherBLUE CROSS PROVIDER
IN0000000392105OtherBLUE CROSS PROVIDER