Provider Demographics
NPI:1093041501
Name:DEFOURNOY, CHRISTIAN JR
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:
Last Name:DEFOURNOY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1880 HYLAN BLVD STE 2R14
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-2116
Mailing Address - Country:US
Mailing Address - Phone:929-312-1468
Mailing Address - Fax:
Practice Address - Street 1:1880 HYLAN BLVD STE 2R14
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-2116
Practice Address - Country:US
Practice Address - Phone:929-312-1468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-19
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY719660163W00000X
NY289076164W00000X
NYF351785363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse