Provider Demographics
NPI:1417788118
Name:FUSCO, ALEXA MARIE
Entity type:Individual
Prefix:
First Name:ALEXA
Middle Name:MARIE
Last Name:FUSCO
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 1:6 PRITCHARD CRES
Mailing Address - Street 2:
Mailing Address - City:PORT JEFF STA
Mailing Address - State:NY
Mailing Address - Zip Code:11776-3218
Mailing Address - Country:US
Mailing Address - Phone:631-903-2882
Mailing Address - Fax:
Practice Address - Street 1:1400 OLD COUNTRY RD STE C103N
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-5156
Practice Address - Country:US
Practice Address - Phone:516-806-6969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1811532241174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist