Healthcare Provider Details

I. General information

NPI: 1184269029
Provider Name (Legal Business Name): ANA FAJARDO LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2019
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 E WILLOW AVE
WHEATON IL
60187-5426
US

IV. Provider business mailing address

619 BELMONT AVE
OSWEGO IL
60543-7729
US

V. Phone/Fax

Practice location:
  • Phone: 630-784-4800
  • Fax:
Mailing address:
  • Phone: 815-216-7016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150.101593
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: