Provider Demographics
NPI:1902565625
Name:FAHERTY, BRENT (FNP)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:
Last Name:FAHERTY
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 DANBURY RD
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06877-4069
Mailing Address - Country:US
Mailing Address - Phone:203-438-0874
Mailing Address - Fax:
Practice Address - Street 1:96 DANBURY RD
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:CT
Practice Address - Zip Code:06877-4069
Practice Address - Country:US
Practice Address - Phone:203-438-0874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-09
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT10273363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily