Healthcare Provider Details

I. General information

NPI: 1265074918
Provider Name (Legal Business Name): STEPHANIE MARIE FAGGIONE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2019
Last Update Date: 10/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 BOXWOOD DR
KINGS PARK NY
11754-2911
US

IV. Provider business mailing address

17 BANK AVE
SMITHTOWN NY
11787-2703
US

V. Phone/Fax

Practice location:
  • Phone: 631-560-0869
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number735771-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: