Provider Demographics
NPI:1710929062
Name:FAHEY-BLEICK, LISA ELEANOR (CNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ELEANOR
Last Name:FAHEY-BLEICK
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14010 COBBLER AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEMOUNT
Mailing Address - State:MN
Mailing Address - Zip Code:55068-7130
Mailing Address - Country:US
Mailing Address - Phone:651-423-1738
Mailing Address - Fax:
Practice Address - Street 1:4178 KNOB DR
Practice Address - Street 2:SUITE A
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-2888
Practice Address - Country:US
Practice Address - Phone:651-209-8640
Practice Address - Fax:651-209-8690
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1205765363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN500003752Medicare PIN
S87600Medicare UPIN