Healthcare Provider Details

I. General information

NPI: 1124027180
Provider Name (Legal Business Name): DEBORAH B FAHS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 N MAIN STREET EXT. BLDG 2 SUITE C2
WALLINGFORD CT
06492
US

IV. Provider business mailing address

850 N MAIN STREET EXT BLDG 2 SUITE C2
WALLINGFORD CT
06492-2400
US

V. Phone/Fax

Practice location:
  • Phone: 203-269-9778
  • Fax: 203-949-1544
Mailing address:
  • Phone: 203-269-9778
  • Fax: 203-949-1544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number001829
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: