Basic Information
Provider Information
NPI: 1851545388
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: FAIRCHILD
FirstName: SHERYL
MiddleName: ANN
NamePrefix:  
NameSuffix:  
Credential: PT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
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OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 16083 SW UPPER BOONES FERRY RD STE 300
Address2:  
City: TIGARD
State: OR
PostalCode: 972247736
CountryCode: US
TelephoneNumber: 5034436156
FaxNumber: 5036399699
Practice Location
Address1: 406 S 1ST ST STE 2
Address2:  
City: SELAH
State: WA
PostalCode: 989421934
CountryCode: US
TelephoneNumber: 5096979109
FaxNumber: 5096979122
Other Information
ProviderEnumerationDate: 11/11/2008
LastUpdateDate: 06/04/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000XPT60041860WAY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

ID Information
IDTypeStateIssuerDescription
109298705WA MEDICAID
4796FA01WAREGENCEOTHER
713056005WA MEDICAID
024362801WAL&IOTHER


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