Provider Demographics
NPI:1376835611
Name:CHIQUITUCTO, ALIZA DIANNE (REGISTERED NURSE)
Entity Type:Individual
Prefix:MRS
First Name:ALIZA
Middle Name:DIANNE
Last Name:CHIQUITUCTO
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 HAGERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-2131
Mailing Address - Country:US
Mailing Address - Phone:516-554-1209
Mailing Address - Fax:
Practice Address - Street 1:310 FORSYTHE AVE
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-2204
Practice Address - Country:US
Practice Address - Phone:516-554-1209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-04
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY636154163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse