1134460736 NPI number — MRS. EDITH MOODY FAULKNER FNP-C

Table of content: MRS. EDITH MOODY FAULKNER FNP-C (NPI 1134460736)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134460736 NPI number — MRS. EDITH MOODY FAULKNER FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAULKNER
Provider First Name:
EDITH
Provider Middle Name:
MOODY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MINYARD
Provider Other First Name:
EDITH
Provider Other Middle Name:
W
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1134460736
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
808 VARSITY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUPELO
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38801-4613
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-377-3204
Provider Business Mailing Address Fax Number:
662-377-2057

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1205 HIGHWAY 182 W STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STARKVILLE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39759-9820
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-377-5199
Provider Business Practice Location Address Fax Number:
662-377-2264
Provider Enumeration Date:
03/06/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  R865568 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 008880771 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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