Provider Demographics
NPI:1487221412
Name:FAHLIN, AMBER (LPN)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:FAHLIN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25671 EMERSON RD
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:WI
Mailing Address - Zip Code:54893-9139
Mailing Address - Country:US
Mailing Address - Phone:715-416-1859
Mailing Address - Fax:
Practice Address - Street 1:4404 STATE ROAD 70
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:WI
Practice Address - Zip Code:54893-9251
Practice Address - Country:US
Practice Address - Phone:715-349-8554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI326080-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse