Provider Demographics
NPI:1154004067
Name:GRAZIANO, VICKI LYNN
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:LYNN
Last Name:GRAZIANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VICKI
Other - Middle Name:LYNN
Other - Last Name:CRUZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:63 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:HOLTSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11742-1046
Mailing Address - Country:US
Mailing Address - Phone:631-834-3484
Mailing Address - Fax:
Practice Address - Street 1:38 BUCKINGHAM DR
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-2880
Practice Address - Country:US
Practice Address - Phone:631-738-0310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist