Provider Demographics
NPI:1154031102
Name:FASOLINO, EMMA ROSE
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:ROSE
Last Name:FASOLINO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2260 DUCK POND RD
Mailing Address - Street 2:
Mailing Address - City:CUTCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11935-1806
Mailing Address - Country:US
Mailing Address - Phone:631-830-1634
Mailing Address - Fax:
Practice Address - Street 1:2260 DUCK POND RD
Practice Address - Street 2:
Practice Address - City:CUTCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11935-1806
Practice Address - Country:US
Practice Address - Phone:631-830-1634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-30
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program