Provider Demographics
NPI:1174573448
Name:FAJARDO, MIRASOL (NP)
Entity type:Individual
Prefix:
First Name:MIRASOL
Middle Name:
Last Name:FAJARDO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3520 CLARINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-4922
Mailing Address - Country:US
Mailing Address - Phone:323-620-4617
Mailing Address - Fax:
Practice Address - Street 1:6240 DESCANSO AVE
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620-1013
Practice Address - Country:US
Practice Address - Phone:714-522-9794
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15932363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health