Healthcare Provider Details

I. General information

NPI: 1528534757
Provider Name (Legal Business Name): NENA FAJARDO PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2018
Last Update Date: 10/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10018 KENNERLY RD
SAINT LOUIS MO
63128-2106
US

IV. Provider business mailing address

1120 KONERT VALLEY DR
FENTON MO
63026-7172
US

V. Phone/Fax

Practice location:
  • Phone: 314-525-8135
  • Fax:
Mailing address:
  • Phone: 314-525-8135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2009020178
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: