Provider Demographics
NPI:1053740712
Name:FAZZALARI, JACQUELINE (LAC)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:
Last Name:FAZZALARI
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5285 72ND PL
Mailing Address - Street 2:APT 2
Mailing Address - City:MASPETH
Mailing Address - State:NY
Mailing Address - Zip Code:11378-1515
Mailing Address - Country:US
Mailing Address - Phone:917-608-2098
Mailing Address - Fax:
Practice Address - Street 1:3749 91ST ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7927
Practice Address - Country:US
Practice Address - Phone:718-775-8990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005209171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist