Provider Demographics
NPI:1740684463
Name:FAULKNER, SAMANTHA LEE (MHA, LAT, ATC)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LEE
Last Name:FAULKNER
Suffix:
Gender:F
Credentials:MHA, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2011 46TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-4919
Mailing Address - Country:US
Mailing Address - Phone:815-303-9909
Mailing Address - Fax:
Practice Address - Street 1:518 W LOCUST ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-2898
Practice Address - Country:US
Practice Address - Phone:815-303-9909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-09
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0011652255A2300X
IL0960048312255A2300X
MO20130301762255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer