Provider Demographics
NPI:1700120128
Name:FAULKNER, ELISE
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:FAULKNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 POWDERHOUSE RD SE
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29803-6245
Mailing Address - Country:US
Mailing Address - Phone:803-507-7055
Mailing Address - Fax:
Practice Address - Street 1:5721 SPRINGFIELD RD
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:SC
Practice Address - Zip Code:29853-1917
Practice Address - Country:US
Practice Address - Phone:803-266-3229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC324225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist