Provider Demographics
NPI:1801595152
Name:OVALLE, FAZEILA (PBT)
Entity type:Individual
Prefix:
First Name:FAZEILA
Middle Name:
Last Name:OVALLE
Suffix:
Gender:F
Credentials:PBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 AVALON GARDENS DR
Mailing Address - Street 2:
Mailing Address - City:NANUET
Mailing Address - State:NY
Mailing Address - Zip Code:10954-7415
Mailing Address - Country:US
Mailing Address - Phone:845-390-0769
Mailing Address - Fax:
Practice Address - Street 1:111 AVALON GARDENS DR
Practice Address - Street 2:
Practice Address - City:NANUET
Practice Address - State:NY
Practice Address - Zip Code:10954-7415
Practice Address - Country:US
Practice Address - Phone:845-390-0769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYQ7F2D7H4374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY92-1618759OtherPHLEBOTOMIST