Provider Demographics
NPI:1104538206
Name:FAIR, KAYLA (RN)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:FAIR
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 BELLEVUE AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-5105
Mailing Address - Country:US
Mailing Address - Phone:937-300-3887
Mailing Address - Fax:
Practice Address - Street 1:1721 HERITAGE LAKE DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45458-6067
Practice Address - Country:US
Practice Address - Phone:937-300-3887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-20
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH505883163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)Group - Single Specialty