Provider Demographics
NPI:1881184414
Name:FAULKNER, TRAVIS JAMES
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:JAMES
Last Name:FAULKNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 DONNYBROOK CT NE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-8345
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:177 DONNYBROOK CT NE
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:MI
Practice Address - Zip Code:49301-8345
Practice Address - Country:US
Practice Address - Phone:616-240-6023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
20000312912255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer