| Doctor Name: | GUDALIA FAJARDO |
| NPI Number: | 1083019012 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | 4704267837 |
| Business Practice Address: | 2603 Electric Ave Ste 1 Port Huron, MI - 480606588 |
| Business Phone Number: | 8109875252 |
| Business Fax Number: | 8109872120 |
| Mailing Address: | 45640 Schoenherr Rd, Suite B UTICA |
| State: | MI |
| Postal Code: | 483156033 |
| Phone Number: | 5862474300 |
| Fax Number: | 5865326496 |
| NPI Enumeration Date: | 11/04/2014 |
| NPI Last Update Date: | 02/17/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LF0000X |
| License Number: | 4704267837 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MI |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Family |
| Taxonomy Definition: | |