Provider Demographics
NPI:1407245798
Name:FAHEY, PENNY
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:FAHEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3355 CARSON DR
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-9202
Mailing Address - Country:US
Mailing Address - Phone:307-709-7887
Mailing Address - Fax:
Practice Address - Street 1:3355 CARSON DR
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-9202
Practice Address - Country:US
Practice Address - Phone:307-709-7887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-09
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator