Provider Demographics
NPI:1144385261
Name:FAHEY, DIANE E (APRN)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:E
Last Name:FAHEY
Suffix:
Gender:F
Credentials:APRN
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Other - First Name:
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Mailing Address - Street 1:755 CAMPBELL AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-3715
Mailing Address - Country:US
Mailing Address - Phone:203-889-2297
Mailing Address - Fax:203-889-2249
Practice Address - Street 1:755 CAMPBELL AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-3715
Practice Address - Country:US
Practice Address - Phone:203-889-2297
Practice Address - Fax:203-889-2249
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2016-05-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CT000373363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001177757Medicaid
CT000373OtherLICENSE NUMBER