Provider Demographics
NPI:1750614400
Name:FAHEY, LAUREN D (PA-C)
Entity type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:D
Last Name:FAHEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:LAUREN
Other - Middle Name:D
Other - Last Name:KEYES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNA
Mailing Address - Street 1:875 AIRPORT PKWY
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-1085
Mailing Address - Country:US
Mailing Address - Phone:317-926-3739
Mailing Address - Fax:
Practice Address - Street 1:725 LAKEFRONT CT
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-5893
Practice Address - Country:US
Practice Address - Phone:317-926-3739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-14
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99039119A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
INPENDINGOtherANTHEM
IN677730YYYMedicare PIN