Provider Demographics
NPI:1720512122
Name:FAIVRE, GERALDINE
Entity type:Individual
Prefix:
First Name:GERALDINE
Middle Name:
Last Name:FAIVRE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GERALDINE
Other - Middle Name:
Other - Last Name:PILISI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 9261
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-9261
Mailing Address - Country:US
Mailing Address - Phone:940-764-7230
Mailing Address - Fax:
Practice Address - Street 1:91-2135 FORT WEAVER RD FL 3
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-1940
Practice Address - Country:US
Practice Address - Phone:808-691-3135
Practice Address - Fax:808-691-3347
Is Sole Proprietor?:No
Enumeration Date:2017-04-12
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXT17002084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program