Provider Demographics
NPI:1134460736
Name:FAULKNER, EDITH MOODY (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:EDITH
Middle Name:MOODY
Last Name:FAULKNER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:MRS
Other - First Name:EDITH
Other - Middle Name:W
Other - Last Name:MINYARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:808 VARSITY DR
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-4613
Mailing Address - Country:US
Mailing Address - Phone:662-377-3204
Mailing Address - Fax:662-377-2057
Practice Address - Street 1:1205 HIGHWAY 182 W STE B
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-9820
Practice Address - Country:US
Practice Address - Phone:662-377-5199
Practice Address - Fax:662-377-2264
Is Sole Proprietor?:No
Enumeration Date:2013-03-06
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR865568363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS008880771Medicaid