Provider Demographics
NPI:1013050319
Name:FAULKNER, JANICE KAY (OPTICIAN OWNER)
Entity Type:Individual
Prefix:MRS
First Name:JANICE
Middle Name:KAY
Last Name:FAULKNER
Suffix:
Gender:F
Credentials:OPTICIAN OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1223 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104
Mailing Address - Country:US
Mailing Address - Phone:817-870-1291
Mailing Address - Fax:817-870-4928
Practice Address - Street 1:1223 5TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:817-870-1291
Practice Address - Fax:817-870-4928
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDR3962156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX066429401Medicaid