Healthcare Provider Details

I. General information

NPI: 1699691261
Provider Name (Legal Business Name): SHONTA R FAULK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 MOSS ST
LAFAYETTE LA
70501-2125
US

IV. Provider business mailing address

1131 EUNICE RD
SAINT MARTINVILLE LA
70582-6107
US

V. Phone/Fax

Practice location:
  • Phone: 337-706-7400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number223005
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: