Provider Demographics
NPI:1366927931
Name:FAZIO, TAYLOR MARIE
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:MARIE
Last Name:FAZIO
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 1:30 W 18TH ST APT 9C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-4671
Mailing Address - Country:US
Mailing Address - Phone:925-628-4015
Mailing Address - Fax:
Practice Address - Street 1:136 MADISON AVE STE 503
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6711
Practice Address - Country:US
Practice Address - Phone:646-660-5661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-30
Last Update Date:2018-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered