MEDICARE: KAYLA FAIR RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WA0400X	Addiction (Substance Use Disorder) Registered Nurse	505883	OH

General Provider Information

NPI Number	:	1104538206
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAYLA FAIR RN

Provider Business Mailing Address
First Line	:	317 BELLEVUE AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45406-5105
Country	:	US
Telephone Number	:	937-300-3887
Fax Number	:

Provider Business Practice Location Address
First Line	:	1721 HERITAGE LAKE DR
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45458-6067
Country	:	US
Telephone Number	:	937-300-3887
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/20/2022
Last Update Date	:	12/20/2022

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