Provider Demographics
NPI:1386069300
Name:DAZA, CHRISTINE ALICE (FNP)
Entity type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:ALICE
Last Name:DAZA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:CHRISTINE
Other - Middle Name:ALICE
Other - Last Name:LUEBCKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1545 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11213-1122
Mailing Address - Country:US
Mailing Address - Phone:718-613-4000
Mailing Address - Fax:
Practice Address - Street 1:1545 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11213-1122
Practice Address - Country:US
Practice Address - Phone:718-613-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-27
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY342378363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner