Provider Demographics
NPI:1083842769
Name:FAULKNER, OSMARA JUDITH (MS)
Entity Type:Individual
Prefix:
First Name:OSMARA
Middle Name:JUDITH
Last Name:FAULKNER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:OSMARA
Other - Middle Name:JUDITH
Other - Last Name:MOREDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:4436 REDCOAT DR
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33543-4855
Mailing Address - Country:US
Mailing Address - Phone:813-951-3567
Mailing Address - Fax:
Practice Address - Street 1:4436 REDCOAT DR
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33543-4855
Practice Address - Country:US
Practice Address - Phone:813-873-1936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-01
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
FLSA10970235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSA10970OtherLICENSE NUMBER
FL000968700Medicaid