Provider Demographics
NPI:1871835223
Name:FAULKNER, GWEN (PHD, MSN)
Entity Type:Individual
Prefix:DR
First Name:GWEN
Middle Name:
Last Name:FAULKNER
Suffix:
Gender:F
Credentials:PHD, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1356 CLOUD AVE
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-6048
Mailing Address - Country:US
Mailing Address - Phone:650-854-8812
Mailing Address - Fax:
Practice Address - Street 1:1356 CLOUD AVE
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-6048
Practice Address - Country:US
Practice Address - Phone:650-854-8812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-25
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN302213364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health