Provider Demographics
NPI:1861899866
Name:FAZZOLARE, CHRISTINA
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:FAZZOLARE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:
Other - Last Name:CICCIONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:333 EARLE OVINGTON BLVD
Mailing Address - Street 2:SUITE 225
Mailing Address - City:UNIONDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11553-3610
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 BROAD ST
Practice Address - Street 2:12TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10004-2304
Practice Address - Country:US
Practice Address - Phone:212-587-8606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-20
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038292225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ4WFH1Medicare PIN