Healthcare Provider Details

I. General information

NPI: 1356829147
Provider Name (Legal Business Name): RYAN THOMAS FAULKNER APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2018
Last Update Date: 08/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4004 LOUISA RD
CATLETTSBURG KY
41129
US

IV. Provider business mailing address

PO BOX 1595
ASHLAND KY
41105-1595
US

V. Phone/Fax

Practice location:
  • Phone: 606-739-6095
  • Fax: 606-739-8252
Mailing address:
  • Phone: 606-408-6200
  • Fax: 606-408-6612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3012580
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.023474
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: