Provider Demographics
NPI:1881129633
Name:PEZZOLLA, MARIA
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:PEZZOLLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1991 NANTUCKET RD
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-1610
Mailing Address - Country:US
Mailing Address - Phone:516-644-7668
Mailing Address - Fax:
Practice Address - Street 1:1400 DEER PARK AVE
Practice Address - Street 2:STE 2
Practice Address - City:NORTH BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11703-1618
Practice Address - Country:US
Practice Address - Phone:631-669-6666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-28
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF340857-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily