Provider Demographics
NPI:1669664702
Name:FAJO, MARLEN A
Entity Type:Individual
Prefix:MRS
First Name:MARLEN
Middle Name:A
Last Name:FAJO
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 1:6555 NW 36TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:VIRGINIA GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33166-6978
Mailing Address - Country:US
Mailing Address - Phone:305-871-2238
Mailing Address - Fax:305-871-2281
Practice Address - Street 1:6555 NW 36TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:VIRGINIA GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33166-6978
Practice Address - Country:US
Practice Address - Phone:305-871-2238
Practice Address - Fax:305-871-2281
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 43909225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist