Provider Demographics
NPI:1790564706
Name:FAIR, KIARA RAYSHAUN (CNM)
Entity Type:Individual
Prefix:
First Name:KIARA
Middle Name:RAYSHAUN
Last Name:FAIR
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4555 W MARTIN LUTHER KING JR BLVD APT 229
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90016-6001
Mailing Address - Country:US
Mailing Address - Phone:323-770-8576
Mailing Address - Fax:
Practice Address - Street 1:4555 W MARTIN LUTHER KING JR BLVD APT 229
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90016-6001
Practice Address - Country:US
Practice Address - Phone:323-770-8576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-28
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95135967163WM0102X
CA236416367A00000X, 176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife