Provider Demographics
NPI:1750386389
Name:FAHEY, MARY LYNN (ARNP)
Entity type:Individual
Prefix:
First Name:MARY LYNN
Middle Name:
Last Name:FAHEY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 SHATTUCK WAY
Mailing Address - Street 2:STE 100
Mailing Address - City:NEWINGTON
Mailing Address - State:NH
Mailing Address - Zip Code:03801-8007
Mailing Address - Country:US
Mailing Address - Phone:603-431-6677
Mailing Address - Fax:603-610-2232
Practice Address - Street 1:1 PORTSMOUTH AVE
Practice Address - Street 2:
Practice Address - City:STRATHAM
Practice Address - State:NH
Practice Address - Zip Code:03885-2585
Practice Address - Country:US
Practice Address - Phone:603-943-3600
Practice Address - Fax:603-630-1009
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH027443-23-03363LP2300X, 363LF0000X
MARN203678363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH2305915YPNH01OtherANTHEM BCBS
NH30008013Medicaid
NH7576040-004OtherCIGNA
NH213938OtherCIGNA
NH213938OtherCIGNA
NHNP0948Medicare ID - Type Unspecified