Healthcare Provider Details

I. General information

NPI: 1174842322
Provider Name (Legal Business Name): ELIZABETH FAJARDO LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2010
Last Update Date: 11/19/2021
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 STEPHAN ST
KINGSTON NY
12401-3045
US

IV. Provider business mailing address

135 STEPHAN ST
KINGSTON NY
12401-3045
US

V. Phone/Fax

Practice location:
  • Phone: 212-390-0884
  • Fax:
Mailing address:
  • Phone: 212-390-0884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number300615
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: