Healthcare Provider Details

I. General information

NPI: 1477151850
Provider Name (Legal Business Name): LAUREN THERESA FAHY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2020
Last Update Date: 10/16/2020
Certification Date: 10/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 ELMORA AVE
ELIZABETH NJ
07208-1576
US

IV. Provider business mailing address

6 ASPEN CT
HAMILTON NJ
08619-4601
US

V. Phone/Fax

Practice location:
  • Phone: 908-659-9200
  • Fax:
Mailing address:
  • Phone: 732-771-6777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number26NJ01066200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: