Provider Demographics
NPI:1265994586
Name:FAY, REGINA MARIE (RN,BSN)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:MARIE
Last Name:FAY
Suffix:
Gender:F
Credentials:RN,BSN
Other - Prefix:
Other - First Name:REGINA
Other - Middle Name:MARIE
Other - Last Name:EGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:1046 S APALACHIN RD
Mailing Address - Street 2:
Mailing Address - City:APALACHIN
Mailing Address - State:NY
Mailing Address - Zip Code:13732-2320
Mailing Address - Country:US
Mailing Address - Phone:607-744-0702
Mailing Address - Fax:
Practice Address - Street 1:1046 S APALACHIN RD
Practice Address - Street 2:
Practice Address - City:APALACHIN
Practice Address - State:NY
Practice Address - Zip Code:13732-2320
Practice Address - Country:US
Practice Address - Phone:607-744-0702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-04
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY579395163W00000X
NYF345035-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY579395OtherREGISTERED NURSE
NYF345035-01OtherFNP LICENSE
F0919-487OtherAMERICAN ACADEMY OF NURSE PRACTITIONERS CERTIFICATION