Provider Demographics
NPI:1932436805
Name:FAZIO, ALESA
Entity Type:Individual
Prefix:MS
First Name:ALESA
Middle Name:
Last Name:FAZIO
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 1:58 HAGERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-2140
Mailing Address - Country:US
Mailing Address - Phone:631-626-4412
Mailing Address - Fax:
Practice Address - Street 1:58 HAGERMAN AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-2140
Practice Address - Country:US
Practice Address - Phone:631-626-4412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-12
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide