Provider Demographics
NPI:1619244340
Name:FAHEY, RENEE M (CHP-C)
Entity type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:M
Last Name:FAHEY
Suffix:
Gender:F
Credentials:CHP-C
Other - Prefix:MS
Other - First Name:RENEE
Other - Middle Name:M
Other - Last Name:OLANNA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CHP-C
Mailing Address - Street 1:85058 CLARENCE ROAD
Mailing Address - Street 2:BOX 85058
Mailing Address - City:BREVIG MISSION
Mailing Address - State:AK
Mailing Address - Zip Code:99785-8505
Mailing Address - Country:US
Mailing Address - Phone:907-642-4311
Mailing Address - Fax:907-642-2216
Practice Address - Street 1:85058 CLARENCE ROAD
Practice Address - Street 2:
Practice Address - City:BREVIG MISSION
Practice Address - State:AK
Practice Address - Zip Code:99785-8505
Practice Address - Country:US
Practice Address - Phone:907-642-4311
Practice Address - Fax:907-642-2216
Is Sole Proprietor?:No
Enumeration Date:2011-11-23
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK11-1153-III172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCHA IIIOther11-1153-III