Healthcare Provider Details

I. General information

NPI: 1700140688
Provider Name (Legal Business Name): RACHAL NICHOLE FAULKNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2012
Last Update Date: 06/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1672 SCIENCE RIDGE RD
JEFFERSONVILLE KY
40337-9686
US

IV. Provider business mailing address

1672 SCIENCE RIDGE RD.
JEFFERSONVILLE KY
40337
US

V. Phone/Fax

Practice location:
  • Phone: 859-398-8567
  • Fax:
Mailing address:
  • Phone: 859-398-8567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: