Provider Demographics
NPI:1497592075
Name:FAHEY, SHANNON M
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:FAHEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:M
Other - Last Name:WAUTIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4976 PLUM BOTTOM RD
Mailing Address - Street 2:
Mailing Address - City:EGG HARBOR
Mailing Address - State:WI
Mailing Address - Zip Code:54209-9147
Mailing Address - Country:US
Mailing Address - Phone:920-418-3330
Mailing Address - Fax:
Practice Address - Street 1:4976 PLUM BOTTOM RD
Practice Address - Street 2:
Practice Address - City:EGG HARBOR
Practice Address - State:WI
Practice Address - Zip Code:54209-9147
Practice Address - Country:US
Practice Address - Phone:920-418-3330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist