Provider Demographics
NPI:1902637135
Name:FAIR, BREANA LYNN
Entity type:Individual
Prefix:
First Name:BREANA
Middle Name:LYNN
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 1:393 WASHINGTON AVE UNIT B
Mailing Address - Street 2:
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80403-1889
Mailing Address - Country:US
Mailing Address - Phone:720-307-7707
Mailing Address - Fax:720-307-7702
Practice Address - Street 1:393 WASHINGTON AVE UNIT B
Practice Address - Street 2:
Practice Address - City:GOLDEN
Practice Address - State:CO
Practice Address - Zip Code:80403-1889
Practice Address - Country:US
Practice Address - Phone:720-307-7707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-09
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0020104225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist