Healthcare Provider Details

I. General information

NPI: 1083019012
Provider Name (Legal Business Name): GUDALIA FAJARDO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2014
Last Update Date: 02/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2603 ELECTRIC AVE STE 1
PORT HURON MI
48060-6588
US

IV. Provider business mailing address

45640 SCHOENHERR RD SUITE B
UTICA MI
48315-6033
US

V. Phone/Fax

Practice location:
  • Phone: 810-987-5252
  • Fax: 810-987-2120
Mailing address:
  • Phone: 586-247-4300
  • Fax: 586-532-6496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704267837
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: