Healthcare Provider Details

I. General information

NPI: 1659849412
Provider Name (Legal Business Name): AN PHAN FAJARDO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2018
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16921 TAYLOR CT
TORRANCE CA
90504-2213
US

IV. Provider business mailing address

16921 TAYLOR CT
TORRANCE CA
90504-2213
US

V. Phone/Fax

Practice location:
  • Phone: 310-292-8179
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number295871
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: