Provider Demographics
NPI:1366981102
Name:FAULKNER, SUSAN ELAINE
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELAINE
Last Name:FAULKNER
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 1:418 WARD AVE
Mailing Address - Street 2:
Mailing Address - City:CARUTHERSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63830-1451
Mailing Address - Country:US
Mailing Address - Phone:573-333-0030
Mailing Address - Fax:573-333-0023
Practice Address - Street 1:418 WARD AVE
Practice Address - Street 2:
Practice Address - City:CARUTHERSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63830-1451
Practice Address - Country:US
Practice Address - Phone:573-333-0030
Practice Address - Fax:573-333-0023
Is Sole Proprietor?:No
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO4917020057897374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1548387145Medicaid
MO1447303664Medicaid