Provider Demographics
NPI:1720354434
Name:FAULKNER, KENNETH MICHAEL (MS, RN, ANP-BC)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:MICHAEL
Last Name:FAULKNER
Suffix:
Gender:M
Credentials:MS, RN, ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:STONY BROOK UNIVERSITY SCHOOL OF NURSING
Mailing Address - Street 2:HSC LEVEL 2
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-0001
Mailing Address - Country:US
Mailing Address - Phone:631-444-3006
Mailing Address - Fax:
Practice Address - Street 1:45 RESEARCH WAY
Practice Address - Street 2:SUITE 204
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-6401
Practice Address - Country:US
Practice Address - Phone:631-444-3006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-27
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA234412163W00000X
NY512108-1163WC0200X
NYF305502-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine