Provider Demographics
NPI:1366761710
Name:FAIR, CARLY MAXIMA
Entity type:Individual
Prefix:MS
First Name:CARLY
Middle Name:MAXIMA
Last Name:FAIR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 WINTER ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02474-6919
Mailing Address - Country:US
Mailing Address - Phone:215-313-5377
Mailing Address - Fax:
Practice Address - Street 1:780 AMERICAN LEGION HWY
Practice Address - Street 2:
Practice Address - City:ROSLINDALE
Practice Address - State:MA
Practice Address - Zip Code:02131-3908
Practice Address - Country:US
Practice Address - Phone:617-469-8557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-25
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program