Provider Demographics
NPI:1235614330
Name:FAHR, BRENDA SUE (PMHNP)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:SUE
Last Name:FAHR
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3407 S KENNEDY DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-8454
Mailing Address - Country:US
Mailing Address - Phone:812-583-4341
Mailing Address - Fax:
Practice Address - Street 1:620 8TH AVE
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47804-2744
Practice Address - Country:US
Practice Address - Phone:812-231-8200
Practice Address - Fax:812-231-8400
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71008386A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health