Healthcare Provider Details

I. General information

NPI: 1700139714
Provider Name (Legal Business Name): VICTORIA TERKISHIA FAULKNER KINESIOTHERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2012
Last Update Date: 10/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 E 9TH ST
BONHAM TX
75418-4059
US

IV. Provider business mailing address

1201 EAST 9TH STREET
BONHAM TX
75418-4059
US

V. Phone/Fax

Practice location:
  • Phone: 180-092-4838
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number226300000X
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: