Provider Demographics
NPI:1538246293
Name:FAULKNER, KIMBERLY HOPE
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:HOPE
Last Name:FAULKNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:HOPE
Other - Last Name:ADKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3641 TEABERRY DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45424-5011
Mailing Address - Country:US
Mailing Address - Phone:937-559-4107
Mailing Address - Fax:
Practice Address - Street 1:3641 TEABERRY DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45424-5011
Practice Address - Country:US
Practice Address - Phone:937-559-4107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2447070Medicaid