Provider Demographics
NPI:1063633543
Name:FAULKNER, BRENDA L (DC)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:L
Last Name:FAULKNER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2205 W. SUDBURY DR.
Mailing Address - Street 2:SUITE B
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403
Mailing Address - Country:US
Mailing Address - Phone:812-333-3131
Mailing Address - Fax:812-333-3181
Practice Address - Street 1:2205 W. SUDBURY DR.
Practice Address - Street 2:SUITE B
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403
Practice Address - Country:US
Practice Address - Phone:812-333-3131
Practice Address - Fax:812-333-3181
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001016A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN595030Medicare ID - Type Unspecified