Provider Demographics
NPI:1417665514
Name:FAIR, KNASTACIA D (LMBT NC #11250)
Entity Type:Individual
Prefix:
First Name:KNASTACIA
Middle Name:D
Last Name:FAIR
Suffix:
Gender:F
Credentials:LMBT NC #11250
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:376 HILLIARD DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-2691
Mailing Address - Country:US
Mailing Address - Phone:704-648-1569
Mailing Address - Fax:
Practice Address - Street 1:376 HILLIARD DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28311-2691
Practice Address - Country:US
Practice Address - Phone:704-648-1569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11250225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist