Provider Demographics
NPI:1245795707
Name:FANE-HERVEY, CARAGH KELLY
Entity type:Individual
Prefix:
First Name:CARAGH
Middle Name:KELLY
Last Name:FANE-HERVEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 COUNTRYSIDE PL SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-8238
Mailing Address - Country:US
Mailing Address - Phone:508-317-4756
Mailing Address - Fax:
Practice Address - Street 1:604 COUNTRYSIDE PL SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-8238
Practice Address - Country:US
Practice Address - Phone:508-317-4756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program