Provider Demographics
NPI:1710997283
Name:FASULO, JOANNA (DC)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:
Last Name:FASULO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 MEDFORD AVE STE C
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-1344
Mailing Address - Country:US
Mailing Address - Phone:631-289-3939
Mailing Address - Fax:
Practice Address - Street 1:680 MEDFORD AVE STE C
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-1344
Practice Address - Country:US
Practice Address - Phone:631-289-3939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX006462111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU33864Medicare UPIN