Provider Demographics
NPI:1528534757
Name:FAJARDO, NENA (PT)
Entity Type:Individual
Prefix:
First Name:NENA
Middle Name:
Last Name:FAJARDO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 KONERT VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-7172
Mailing Address - Country:US
Mailing Address - Phone:314-525-8135
Mailing Address - Fax:
Practice Address - Street 1:10018 KENNERLY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2106
Practice Address - Country:US
Practice Address - Phone:314-525-8135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009020178225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist