Provider Demographics
NPI:1114077039
Name:FAHEY, PATRICIA (FNP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:FAHEY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 US ROUTE 1
Mailing Address - Street 2:BUILDING C
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-7609
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:887 CONGRESS ST
Practice Address - Street 2:SUITE 210
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3100
Practice Address - Country:US
Practice Address - Phone:207-774-2544
Practice Address - Fax:207-774-0459
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER034517363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431740799Medicaid
NH30343484Medicaid
MENP4970Medicare PIN
Q39679Medicare UPIN
ME431740799Medicaid
NH30343484Medicaid
MENP497001Medicare PIN