Provider Demographics
NPI:1073179941
Name:FAJARDO, ESTELA
Entity Type:Individual
Prefix:
First Name:ESTELA
Middle Name:
Last Name:FAJARDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5329 24TH STREET CT E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34203-4929
Mailing Address - Country:US
Mailing Address - Phone:941-524-0946
Mailing Address - Fax:
Practice Address - Street 1:5329 24TH STREET CT E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34203-4929
Practice Address - Country:US
Practice Address - Phone:941-524-0946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-15
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9186738163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse