Provider Demographics
NPI:1124538822
Name:FAJARDO, ANITA
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:FAJARDO
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 1:7433 46TH AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-3008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7433 46TH AVE FL 1
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-3008
Practice Address - Country:US
Practice Address - Phone:917-349-2480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-07
Last Update Date:2017-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist