Provider Demographics
NPI:1942246244
Name:FAHERTY, CYNTHIA MARIE (CRNP)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:MARIE
Last Name:FAHERTY
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:M
Other - Last Name:SCHUSTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:5230 CAMPBELL BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:WHITE MARSH
Mailing Address - State:MD
Mailing Address - Zip Code:21236
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5230 CAMPBELL BOULEVARD
Practice Address - Street 2:
Practice Address - City:WHITE MARSH
Practice Address - State:MD
Practice Address - Zip Code:21236
Practice Address - Country:US
Practice Address - Phone:410-550-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR153439363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD010387000Medicaid
MDQ71601Medicare UPIN
MDKR37O395Medicare ID - Type Unspecified