Provider Demographics
NPI:1780179093
Name:FAJARDO, MELANIE (PT, DPT)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:FAJARDO
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1819 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19806-2520
Mailing Address - Country:US
Mailing Address - Phone:301-642-1387
Mailing Address - Fax:
Practice Address - Street 1:720 YORKLYN RD STE 150
Practice Address - Street 2:
Practice Address - City:HOCKESSIN
Practice Address - State:DE
Practice Address - Zip Code:19707-8729
Practice Address - Country:US
Practice Address - Phone:302-234-2288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0003918225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist