Healthcare Provider Details

I. General information

NPI: 1730593393
Provider Name (Legal Business Name): LISA FAULK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2014
Last Update Date: 06/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BUILDING 301 ANDREWS AVENUE LYSTER ARMY HEALTH CLINIC
FORT RUCKER AL
36362-5333
US

IV. Provider business mailing address

BUILDING 301 ANDREWS AVENUE LYSTER ARMY HEALTH CLINIC
FORT RUCKER AL
36362-5333
US

V. Phone/Fax

Practice location:
  • Phone: 334-255-7577
  • Fax:
Mailing address:
  • Phone: 334-255-7577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number1-097765
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: