Provider Demographics
NPI:1689045353
Name:FAULKNER, WILMA BLAKE (LAC, DIPL OM)
Entity Type:Individual
Prefix:MRS
First Name:WILMA
Middle Name:BLAKE
Last Name:FAULKNER
Suffix:
Gender:F
Credentials:LAC, DIPL OM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4806 DAVENPORT TRCE NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-3974
Mailing Address - Country:US
Mailing Address - Phone:336-671-0186
Mailing Address - Fax:
Practice Address - Street 1:4900 IVEY RD NW
Practice Address - Street 2:SUITE 820
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-4001
Practice Address - Country:US
Practice Address - Phone:770-975-9233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA371171100000X
NC496171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist