Healthcare Provider Details

I. General information

NPI: 1588072771
Provider Name (Legal Business Name): LA KEISHA FAIR MAE, ATC,LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2014
Last Update Date: 07/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CUMBERLAND SQUARE
LEBANON TN
37087
US

IV. Provider business mailing address

1 CUMBERLAND SQ
LEBANON TN
37087-3408
US

V. Phone/Fax

Practice location:
  • Phone: 615-453-6327
  • Fax:
Mailing address:
  • Phone: 615-453-6327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number0000001348
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: