Provider Demographics
NPI:1912064437
Name:FAJARDO, DIANNE JASMIN (CNM)
Entity Type:Individual
Prefix:MRS
First Name:DIANNE
Middle Name:JASMIN
Last Name:FAJARDO
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 CRAIG ST
Mailing Address - Street 2:
Mailing Address - City:COPPERAS COVE
Mailing Address - State:TX
Mailing Address - Zip Code:76522
Mailing Address - Country:US
Mailing Address - Phone:254-547-1808
Mailing Address - Fax:254-547-1808
Practice Address - Street 1:36000 DARNALL LOOP
Practice Address - Street 2:
Practice Address - City:FT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544
Practice Address - Country:US
Practice Address - Phone:254-288-8256
Practice Address - Fax:254-286-7327
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX525288176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife