Provider Demographics
NPI:1659869444
Name:FAHY, ANNSLEE (FCS-DIETETICS)
Entity Type:Individual
Prefix:
First Name:ANNSLEE
Middle Name:
Last Name:FAHY
Suffix:
Gender:F
Credentials:FCS-DIETETICS
Other - Prefix:
Other - First Name:ANNSLEE
Other - Middle Name:
Other - Last Name:MERKEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1107 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2600
Mailing Address - Country:US
Mailing Address - Phone:217-223-8400
Mailing Address - Fax:217-214-5888
Practice Address - Street 1:1107 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2600
Practice Address - Country:US
Practice Address - Phone:217-223-8400
Practice Address - Fax:217-214-5888
Is Sole Proprietor?:No
Enumeration Date:2018-04-26
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015002780133N00000X
IL164-006419133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist