Healthcare Provider Details

I. General information

NPI: 1386113066
Provider Name (Legal Business Name): RYAN JACK PAUL FAULKNER FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2018
Last Update Date: 08/25/2021
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8401 PICARDY AVE
BATON ROUGE LA
70809-3685
US

IV. Provider business mailing address

8401 PICARDY AVE
BATON ROUGE LA
70809-3685
US

V. Phone/Fax

Practice location:
  • Phone: 225-308-0247
  • Fax: 225-308-0249
Mailing address:
  • Phone: 225-308-0247
  • Fax: 225-308-0249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number200992
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: