Provider Demographics
NPI:1629472774
Name:FAIN, CELINA (HAD)
Entity Type:Individual
Prefix:
First Name:CELINA
Middle Name:
Last Name:FAIN
Suffix:
Gender:F
Credentials:HAD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 LAKE HAVASU AVE S STE 103
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-0811
Mailing Address - Country:US
Mailing Address - Phone:928-855-9770
Mailing Address - Fax:928-855-9774
Practice Address - Street 1:55 LAKE HAVASU AVE S STE L
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-0938
Practice Address - Country:US
Practice Address - Phone:928-855-9770
Practice Address - Fax:928-855-9774
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-17
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZHAD6181174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist