Provider Demographics
NPI:1053036574
Name:FAULKNER, KRISTIE NICOLE
Entity type:Individual
Prefix:
First Name:KRISTIE
Middle Name:NICOLE
Last Name:FAULKNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTIE
Other - Middle Name:NICOLE
Other - Last Name:MIES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 N JUBILEE ST
Mailing Address - Street 2:
Mailing Address - City:ANDALE
Mailing Address - State:KS
Mailing Address - Zip Code:67001-9662
Mailing Address - Country:US
Mailing Address - Phone:316-213-5845
Mailing Address - Fax:
Practice Address - Street 1:300 N JUBILEE ST
Practice Address - Street 2:
Practice Address - City:ANDALE
Practice Address - State:KS
Practice Address - Zip Code:67001-9662
Practice Address - Country:US
Practice Address - Phone:316-213-5845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-06
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-02915225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant