Provider Demographics
NPI:1275717696
Name:FAHEY, MAUREEN SUSAN (OD)
Entity Type:Individual
Prefix:DR
First Name:MAUREEN
Middle Name:SUSAN
Last Name:FAHEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8503 W CLEARWATER AVE
Mailing Address - Street 2:STE A
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-3100
Mailing Address - Country:US
Mailing Address - Phone:509-735-2050
Mailing Address - Fax:509-735-2288
Practice Address - Street 1:8503 W CLEARWATER AVE
Practice Address - Street 2:STE A
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-3100
Practice Address - Country:US
Practice Address - Phone:509-735-2050
Practice Address - Fax:509-735-2288
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-20
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWA00003148152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2032142Medicaid
WAU43761OtherUPIN
WAU43761OtherUPIN
WA6209730001Medicare NSC