1134123649 NPI number — MRS. NINA MICHAEL FULKERSON APRN

Table of content: MRS. NINA MICHAEL FULKERSON APRN (NPI 1134123649)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134123649 NPI number — MRS. NINA MICHAEL FULKERSON APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FULKERSON
Provider First Name:
NINA
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134123649
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
401 E CHESTNUT ST
Provider Second Line Business Mailing Address:
STE #510
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40202-5700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-589-0802
Provider Business Mailing Address Fax Number:
502-589-0805

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2360 STONY BROOK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40220-4018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-446-5462
Provider Business Practice Location Address Fax Number:
502-394-3670
Provider Enumeration Date:
06/13/2005

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:  3003622 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7100005460 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".