Provider Demographics
NPI:1679389944
Name:FAIRMAN, FREDERICKA LYNETTE
Entity type:Individual
Prefix:MISS
First Name:FREDERICKA
Middle Name:LYNETTE
Last Name:FAIRMAN
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 1:504 EASTGATE DR
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-3106
Mailing Address - Country:US
Mailing Address - Phone:601-748-1731
Mailing Address - Fax:
Practice Address - Street 1:504 EASTGATE DR
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-3106
Practice Address - Country:US
Practice Address - Phone:601-748-1731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-10
Last Update Date:2025-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS083949376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide