Provider Demographics
NPI:1093472532
Name:FAJARDO, LENNY VALESKA
Entity Type:Individual
Prefix:
First Name:LENNY
Middle Name:VALESKA
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 1:321 W 125TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-3637
Mailing Address - Country:US
Mailing Address - Phone:929-732-8829
Mailing Address - Fax:
Practice Address - Street 1:102 CLIFTON PL APT 3D
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-7218
Practice Address - Country:US
Practice Address - Phone:929-732-8829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-18
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032745225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty