Provider Demographics
NPI:1477151850
Name:FAHY, LAUREN THERESA
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:THERESA
Last Name:FAHY
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 1:6 ASPEN CT
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08619-4601
Mailing Address - Country:US
Mailing Address - Phone:732-771-6777
Mailing Address - Fax:
Practice Address - Street 1:435 ELMORA AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07208-1576
Practice Address - Country:US
Practice Address - Phone:908-659-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01066200363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics