Healthcare Provider Details

I. General information

NPI: 1629316005
Provider Name (Legal Business Name): CHELSEA FAIRBANKS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2013
Last Update Date: 01/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2536 LAGUNA VISTA DR
NOVATO CA
94945-1526
US

IV. Provider business mailing address

2536 LAGUNA VISTA DR
NOVATO CA
94945-1526
US

V. Phone/Fax

Practice location:
  • Phone: 415-250-0797
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberD7571234
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: