Healthcare Provider Details

I. General information

NPI: 1508988742
Provider Name (Legal Business Name): JENNIFER MARIE DEFAZIO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 02/07/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 MOYE BLVD
GREENVILLE NC
27834-2849
US

IV. Provider business mailing address

PO BOX 751069
CHARLOTTE NC
28275-1069
US

V. Phone/Fax

Practice location:
  • Phone: 252-744-3109
  • Fax: 252-744-2096
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number2009-01325
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number22380
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: