MEDICARE: MS. DIANE E FAHEY APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0200X	Pediatric Nurse Practitioner	000373	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	000373	OTHER	CT	LICENSE NUMBER

General Provider Information

NPI Number	:	1144385261
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DIANE E FAHEY APRN

Provider Business Mailing Address
First Line	:	755 CAMPBELL AVE
Second Line	:	SUITE 2
City	:	WEST HAVEN
State	:	CT
Zip	:	06516-3715
Country	:	US
Telephone Number	:	203-889-2297
Fax Number	:	203-889-2249

Provider Business Practice Location Address
First Line	:	755 CAMPBELL AVE
Second Line	:	SUITE 2
City	:	WEST HAVEN
State	:	CT
Zip	:	06516-3715
Country	:	US
Telephone Number	:	203-889-2297
Fax Number	:	203-889-2249

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/27/2006
Last Update Date	:	05/03/2016

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Directions to “ MS. DIANE E FAHEY APRN” Practice Location

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