Provider Demographics
NPI:1477240448
Name:FAULK, LINDA GRAY
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:GRAY
Last Name:FAULK
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 1:5521 COLONIAL CHATSWORTH CIR
Mailing Address - Street 2:
Mailing Address - City:N CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29418-2752
Mailing Address - Country:US
Mailing Address - Phone:336-394-2216
Mailing Address - Fax:
Practice Address - Street 1:109 BEE ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-5703
Practice Address - Country:US
Practice Address - Phone:843-577-5011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-20
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered