Provider Demographics
NPI:1306669312
Name:FASSOIS, ASHLEY LYNNE (NP)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:LYNNE
Last Name:FASSOIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:LYNNE
Other - Last Name:BONANNO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:236 HOLBROOK AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-1841
Mailing Address - Country:US
Mailing Address - Phone:631-312-2944
Mailing Address - Fax:
Practice Address - Street 1:1320 STONY BROOK RD STE 100
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2222
Practice Address - Country:US
Practice Address - Phone:631-941-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-07
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF311865-01363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health