Provider Demographics
NPI:1851810303
Name:FAULKNER, ANGELA MARIE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:MARIE
Last Name:FAULKNER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:100 NAVARRE PL STE 4410
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1171
Practice Address - Country:US
Practice Address - Phone:574-647-1650
Practice Address - Fax:574-647-1655
Is Sole Proprietor?:No
Enumeration Date:2017-09-15
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71007553A363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN181980009OtherMEDICARE PTAN
IN300007994Medicaid
IN181980009OtherMEDICARE PTAN