Provider Demographics
NPI:1528554508
Name:FAULK, KATELYNN (PA)
Entity Type:Individual
Prefix:
First Name:KATELYNN
Middle Name:
Last Name:FAULK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2412 CLAIRBORNE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76177-8203
Mailing Address - Country:US
Mailing Address - Phone:807-773-5504
Mailing Address - Fax:
Practice Address - Street 1:9509 N BEACH ST STE 101
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-6399
Practice Address - Country:US
Practice Address - Phone:817-741-4347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-02
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA12106363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant