Healthcare Provider Details

I. General information

NPI: 1801527023
Provider Name (Legal Business Name): SAMANTHA JANE FAJARDO-LEGASPI RN, PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2022
Last Update Date: 10/08/2025
Certification Date: 10/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 W END AVE
GREAT NECK NY
11023-1212
US

IV. Provider business mailing address

6459 223RD PL APT 250B
OAKLAND GARDENS NY
11364-2344
US

V. Phone/Fax

Practice location:
  • Phone: 917-732-3936
  • Fax:
Mailing address:
  • Phone: 917-732-3936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number053201
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number642748
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: