=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548979701
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARLY WALKER FAULKENBURY NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2022
-----------------------------------------------------
Last Update Date | 07/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 123 SHADOW RIDGE DR
-----------------------------------------------------
City | GRAHAM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27253-8432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-630-6249
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 224 GRAND HILL PL
-----------------------------------------------------
City | HOLLY SPRINGS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27540-4483
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-295-9483
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | FAULK-AE38Y
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------