Provider Demographics
NPI:1134509136
Name:DESTINE-AZOR, MARIE SMITH (FNP)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:SMITH
Last Name:DESTINE-AZOR
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:S
Other - Last Name:DESTINE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:3110 MILBURN AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-4453
Mailing Address - Country:US
Mailing Address - Phone:516-376-1383
Mailing Address - Fax:516-223-2331
Practice Address - Street 1:3000 MARCUS AVE STE 2W15
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1005
Practice Address - Country:US
Practice Address - Phone:855-201-4988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-04
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF339116-1363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner