Provider Demographics
NPI:1669586418
Name:FAULKNER, AMY B (PT)
Entity type:Individual
Prefix:MS
First Name:AMY
Middle Name:B
Last Name:FAULKNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1567 BRONCO DRIVE
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940
Mailing Address - Country:US
Mailing Address - Phone:321-543-1604
Mailing Address - Fax:
Practice Address - Street 1:2129 W NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:W MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904
Practice Address - Country:US
Practice Address - Phone:321-724-0060
Practice Address - Fax:321-724-6775
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT12123225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist