Healthcare Provider Details

I. General information

NPI: 1255864849
Provider Name (Legal Business Name): LUCIA FAJARDO NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2017
Last Update Date: 04/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7908 RANCHO FANITA DR SPC 20
SANTEE CA
92071-3421
US

IV. Provider business mailing address

7908 RANCHO FANITA DR SPC 20
SANTEE CA
92071-3421
US

V. Phone/Fax

Practice location:
  • Phone: 619-900-5365
  • Fax:
Mailing address:
  • Phone: 619-900-5365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number806303
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: