Basic Information
| Provider Information | |||||||||
| NPI: | 1659869444 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAHY | ||||||||
| FirstName: | ANNSLEE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | FCS-DIETETICS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MERKEL | ||||||||
| OtherFirstName: | ANNSLEE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1107 COLLEGE AVE | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623012600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172238400 | ||||||||
| FaxNumber: | 2172145888 | ||||||||
| Practice Location | |||||||||
| Address1: | 1107 COLLEGE AVE | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623012600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172238400 | ||||||||
| FaxNumber: | 2172145888 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2018 | ||||||||
| LastUpdateDate: | 04/26/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133N00000X | 2015002780 | MO | N | Dietary & Nutritional Service Providers | Nutritionist | 133V00000X | 164-006419 | IL | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.