Provider Demographics
NPI:1740859305
Name:FOGO, LAJAUN
Entity type:Individual
Prefix:
First Name:LAJAUN
Middle Name:
Last Name:FOGO
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 1:374 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06053-3960
Mailing Address - Country:US
Mailing Address - Phone:860-477-6681
Mailing Address - Fax:
Practice Address - Street 1:167 N CHESTNUT HILL RD
Practice Address - Street 2:
Practice Address - City:KILLINGWORTH
Practice Address - State:CT
Practice Address - Zip Code:06419-1002
Practice Address - Country:US
Practice Address - Phone:860-510-1709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTNA9993981376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty