Provider Demographics
NPI:1609480631
Name:FAULKNER, TYLER (LAT, ATC, CES)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:FAULKNER
Suffix:
Gender:M
Credentials:LAT, ATC, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHESTERTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21620-1438
Mailing Address - Country:US
Mailing Address - Phone:860-383-3842
Mailing Address - Fax:
Practice Address - Street 1:300 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:CHESTERTOWN
Practice Address - State:MD
Practice Address - Zip Code:21620-1197
Practice Address - Country:US
Practice Address - Phone:860-383-3842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-08
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0039832255A2300X
MDA014052255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer