Provider Demographics
NPI:1982996195
Name:WALLACE-FAIR, CARONIA PHILESIA (DO)
Entity Type:Individual
Prefix:MISS
First Name:CARONIA
Middle Name:PHILESIA
Last Name:WALLACE-FAIR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:MRS
Other - First Name:CARONIA
Other - Middle Name:PHILESIA
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:39868 AVENUE 7 1/2
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93636
Mailing Address - Country:US
Mailing Address - Phone:305-331-6955
Mailing Address - Fax:
Practice Address - Street 1:9300 VALLEY CHILDRENS PL
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93636-8761
Practice Address - Country:US
Practice Address - Phone:559-353-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA15444207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program