Provider Demographics
NPI:1134408602
Name:DEFOURNOY, CHRISTY K
Entity type:Individual
Prefix:
First Name:CHRISTY
Middle Name:K
Last Name:DEFOURNOY
Suffix:
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 1:2053 23RD ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-3245
Mailing Address - Country:US
Mailing Address - Phone:631-626-6796
Mailing Address - Fax:
Practice Address - Street 1:68 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-5760
Practice Address - Country:US
Practice Address - Phone:631-482-0219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-15
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY347189363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily