Provider Demographics
NPI:1497054696
Name:FAULK, CONSTANCE STITT
Entity Type:Individual
Prefix:MRS
First Name:CONSTANCE
Middle Name:STITT
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 1:3968 HUNTERS LAKE CIR W
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-4667
Mailing Address - Country:US
Mailing Address - Phone:904-704-0679
Mailing Address - Fax:
Practice Address - Street 1:3968 HUNTERS LAKE CIR W
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-4667
Practice Address - Country:US
Practice Address - Phone:904-779-2355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-28
Last Update Date:2011-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL682598298Medicaid
FL682598296Medicaid