Healthcare Provider Details

I. General information

NPI: 1992509954
Provider Name (Legal Business Name): MARCO LORENZO FAJARDO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2025
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MANNING DR
CHAPEL HILL NC
27514-4220
US

IV. Provider business mailing address

206 WESTBROOK DR
CARRBORO NC
27510-2447
US

V. Phone/Fax

Practice location:
  • Phone: 203-233-9261
  • Fax:
Mailing address:
  • Phone: 203-233-9261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number5022373
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: