Healthcare Provider Details

I. General information

NPI: 1710262852
Provider Name (Legal Business Name): RONETH FAJARDO R.P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2011
Last Update Date: 10/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6445 GERMANTOWN AVE
PHILADELPHIA PA
19119-2345
US

IV. Provider business mailing address

139 FULTON ST SUITE 502
NEW YORK NY
10038-2594
US

V. Phone/Fax

Practice location:
  • Phone: 215-438-5268
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License NumberPT020320
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number029125
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: