Provider Demographics
NPI:1083019012
Name:FAJARDO, GUDALIA
Entity Type:Individual
Prefix:
First Name:GUDALIA
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 1:45640 SCHOENHERR RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:UTICA
Mailing Address - State:MI
Mailing Address - Zip Code:48315-6033
Mailing Address - Country:US
Mailing Address - Phone:586-247-4300
Mailing Address - Fax:586-532-6496
Practice Address - Street 1:2603 ELECTRIC AVE STE 1
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-6588
Practice Address - Country:US
Practice Address - Phone:810-987-5252
Practice Address - Fax:810-987-2120
Is Sole Proprietor?:No
Enumeration Date:2014-11-04
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704267837363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily