Healthcare Provider Details

I. General information

NPI: 1396625570
Provider Name (Legal Business Name): FULLER LIFE HEALTH AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2025
Last Update Date: 09/06/2025
Certification Date: 09/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 HUNTER CT STE 3
BOWLING GREEN KY
42103-7032
US

IV. Provider business mailing address

431 CLAYPOOL BOYCE RD
ALVATON KY
42122-8732
US

V. Phone/Fax

Practice location:
  • Phone: 270-904-5104
  • Fax:
Mailing address:
  • Phone: 270-904-5104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KRISTINA WATT FULLER
Title or Position: OWNER
Credential: LPCC-S
Phone: 270-791-8189