Provider Demographics
NPI:1083115331
Name:FAULTER, VICKIE
Entity Type:Individual
Prefix:
First Name:VICKIE
Middle Name:
Last Name:FAULTER
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:PO BOX 355
Mailing Address - Street 2:
Mailing Address - City:LOMETA
Mailing Address - State:TX
Mailing Address - Zip Code:76853-0355
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:522 COUNTY RD 2509
Practice Address - Street 2:
Practice Address - City:LONETA
Practice Address - State:TX
Practice Address - Zip Code:76853
Practice Address - Country:US
Practice Address - Phone:512-752-8461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX709542163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX709542Medicaid