Provider Demographics
NPI:1982989331
Name:FIELDS-FAHY, BONITA
Entity Type:Individual
Prefix:MRS
First Name:BONITA
Middle Name:
Last Name:FIELDS-FAHY
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 1:6491 BOBCAT RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89122-3612
Mailing Address - Country:US
Mailing Address - Phone:414-588-9195
Mailing Address - Fax:
Practice Address - Street 1:6491 BOBCAT RIDGE AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89122-3612
Practice Address - Country:US
Practice Address - Phone:414-588-9195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health