Provider Demographics
NPI:1972365716
Name:FAULKNER, SEAN
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
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 1:639 38TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-2210
Mailing Address - Country:US
Mailing Address - Phone:309-794-8793
Mailing Address - Fax:309-794-8709
Practice Address - Street 1:639 38TH ST
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-2296
Practice Address - Country:US
Practice Address - Phone:309-794-8793
Practice Address - Fax:309-794-8709
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-26
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960045872255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer