Healthcare Provider Details

I. General information

NPI: 1033179882
Provider Name (Legal Business Name): ELIZABETH ANNE FAULK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 04/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1375 UNIVERSITY ST
HEALDSBURG CA
95448-3382
US

IV. Provider business mailing address

1375 UNIVERSITY ST
HEALDSBURG CA
95448-3382
US

V. Phone/Fax

Practice location:
  • Phone: 925-482-8249
  • Fax: 925-482-2834
Mailing address:
  • Phone: 925-482-8249
  • Fax: 925-482-2834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number26815
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberC54851
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: