Provider Demographics
NPI:1932145158
Name:BOISCLAIR-FAHEY, ANNE LOUISE (NP)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:LOUISE
Last Name:BOISCLAIR-FAHEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - Street 2:420 DELAWARE STREET SE, MMC 394
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-626-6666
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY OF MINNESOTA PHYSICIANS
Practice Address - Street 2:516 DELAWARE STREET SE, PWB FIRST FLOOR, CLINIC 1E
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455
Practice Address - Country:US
Practice Address - Phone:612-626-6666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 083633-9363L00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP19824OtherHEALTHPARTNERS
MN1014054OtherPREFERRED ONE
MN12-02883OtherMEDICA PRIMARY
MN12-02906OtherMEDICA CHOICE
MN120222OtherUCARE
MN1401466OtherARAZ
MT4303091Medicaid