Provider Demographics
NPI:1831413087
Name:FAZYLOV, NATELLA (RPH)
Entity type:Individual
Prefix:MRS
First Name:NATELLA
Middle Name:
Last Name:FAZYLOV
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11829A METROPOLITAN AVE
Mailing Address - Street 2:
Mailing Address - City:KEW GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11415-2020
Mailing Address - Country:US
Mailing Address - Phone:718-487-8100
Mailing Address - Fax:718-487-8300
Practice Address - Street 1:11829A METROPOLITAN AVE
Practice Address - Street 2:
Practice Address - City:KEW GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11415-2020
Practice Address - Country:US
Practice Address - Phone:718-487-8100
Practice Address - Fax:718-487-8300
Is Sole Proprietor?:No
Enumeration Date:2010-03-17
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046354183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02350232Medicaid