Provider Demographics
NPI:1013961895
Name:FAULKNER, KELLY D (ARNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:D
Last Name:FAULKNER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7208
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42002-7208
Mailing Address - Country:US
Mailing Address - Phone:270-415-9575
Mailing Address - Fax:270-415-9576
Practice Address - Street 1:5150 VILLAGE SQUARE DRIVE
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-9060
Practice Address - Country:US
Practice Address - Phone:270-415-9575
Practice Address - Fax:270-415-9576
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4806P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner