Healthcare Provider Details

I. General information

NPI: 1215248018
Provider Name (Legal Business Name): DOMINIQUE AZOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2010
Last Update Date: 06/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1477 E 33RD ST
BROOKLYN NY
11234-3434
US

IV. Provider business mailing address

1477 E 33RD ST
BROOKLYN NY
11234-3434
US

V. Phone/Fax

Practice location:
  • Phone: 347-272-8354
  • Fax:
Mailing address:
  • Phone: 347-272-8354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number515590
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: