Individual
DEBORA CLARK FAIRFAX
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
164 W 121ST ST, NEW YORK, NY 10027-6324
(212) 866-2964
Mailing address
164 W 121ST ST, NEW YORK, NY 10027-6324
(212) 866-2964
Taxonomy
Speciality
Code
Description
License number
State
171W00000X
Contractor
Primary
—
NY
Other
Enumeration date
06/19/2012
Last updated
06/19/2012
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