Provider Demographics
NPI:1609462092
Name:FAULKNER, MISTY (RDN)
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:
Last Name:FAULKNER
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 VIA BARQUERO
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069-7395
Mailing Address - Country:US
Mailing Address - Phone:858-373-8146
Mailing Address - Fax:
Practice Address - Street 1:50100 GOLSH RD
Practice Address - Street 2:
Practice Address - City:VALLEY CENTER
Practice Address - State:CA
Practice Address - Zip Code:92082-5338
Practice Address - Country:US
Practice Address - Phone:760-749-1410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-18
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86151025133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered