Healthcare Provider Details

I. General information

NPI: 1184383366
Provider Name (Legal Business Name): PERLITA R FAJARDO RRT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: PERLITA G RAMOS RRT

II. Dates (important events)

Enumeration Date: 12/15/2021
Last Update Date: 12/15/2021
Certification Date: 12/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CORNER ROUTE N12 AND N7
FORT DEFIANCE AZ
86504-0649
US

IV. Provider business mailing address

PO BOX 649
FORT DEFIANCE AZ
86504-0649
US

V. Phone/Fax

Practice location:
  • Phone: 928-729-8132
  • Fax:
Mailing address:
  • Phone: 928-729-8132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number43ZA00508900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: