Provider Demographics
NPI:1174842322
Name:FAJARDO, ELIZABETH (LPN)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:
Last Name:FAJARDO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 STEPHAN ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-3045
Mailing Address - Country:US
Mailing Address - Phone:212-390-0884
Mailing Address - Fax:
Practice Address - Street 1:135 STEPHAN ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-3045
Practice Address - Country:US
Practice Address - Phone:212-390-0884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-27
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY300615164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse