Provider Demographics
NPI:1245338102
Name:FAJARDO, GINELLE VILA-DULAY (PT)
Entity type:Individual
Prefix:MS
First Name:GINELLE
Middle Name:VILA-DULAY
Last Name:FAJARDO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:GINELLE
Other - Middle Name:VILA
Other - Last Name:DULAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2311 S MIRA CT UNIT 127
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92802-3532
Mailing Address - Country:US
Mailing Address - Phone:714-971-8763
Mailing Address - Fax:
Practice Address - Street 1:215 N STATE COLLEGE BLVD
Practice Address - Street 2:SUITE G
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-2932
Practice Address - Country:US
Practice Address - Phone:714-999-6596
Practice Address - Fax:714-999-5009
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT29347225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist