Provider Demographics
NPI:1821277682
Name:THEODULE FAHY, JOHANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHANNE
Middle Name:
Last Name:THEODULE FAHY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16450 104TH AVE
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-5413
Mailing Address - Country:US
Mailing Address - Phone:708-349-0070
Mailing Address - Fax:708-349-0077
Practice Address - Street 1:16450 104TH AVE
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-5413
Practice Address - Country:US
Practice Address - Phone:708-349-0070
Practice Address - Fax:708-349-0077
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003125363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical