Provider Demographics
NPI:1831219294
Name:FAHEY, ELLEN M (APRN)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:M
Last Name:FAHEY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 CROSS ST
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-4647
Mailing Address - Country:US
Mailing Address - Phone:203-229-2000
Mailing Address - Fax:203-840-9001
Practice Address - Street 1:40 CROSS ST
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-4647
Practice Address - Country:US
Practice Address - Phone:203-229-2000
Practice Address - Fax:203-840-9001
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003297363LP0200X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT08047561Medicaid