Healthcare Provider Details

I. General information

NPI: 1366179160
Provider Name (Legal Business Name): CHARLOTTE FOUNTAIN FAULKNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2022
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3495 HOFFMAN ST
GREEN COVE SPRINGS FL
32043-4770
US

IV. Provider business mailing address

188 RIVERWALK BLVD
ST JOHNS FL
32259-8622
US

V. Phone/Fax

Practice location:
  • Phone: 904-284-8200
  • Fax:
Mailing address:
  • Phone: 904-521-5719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: