Provider Demographics
NPI:1164726212
Name:FAHEY, KEALSYE NICOLA JUNE (LMP)
Entity Type:Individual
Prefix:MISS
First Name:KEALSYE
Middle Name:NICOLA JUNE
Last Name:FAHEY
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7910 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98408-7031
Mailing Address - Country:US
Mailing Address - Phone:253-473-3733
Mailing Address - Fax:
Practice Address - Street 1:7910 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98408-7031
Practice Address - Country:US
Practice Address - Phone:253-473-3733
Practice Address - Fax:253-473-9517
Is Sole Proprietor?:No
Enumeration Date:2011-01-04
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60152825225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist