Healthcare Provider Details

I. General information

NPI: 1134123649
Provider Name (Legal Business Name): NINA MICHAEL FULKERSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 10/16/2020
Certification Date: 10/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2360 STONY BROOK DR
LOUISVILLE KY
40220-4018
US

IV. Provider business mailing address

401 E CHESTNUT ST STE #510
LOUISVILLE KY
40202-5700
US

V. Phone/Fax

Practice location:
  • Phone: 502-446-5462
  • Fax: 502-394-3670
Mailing address:
  • Phone: 502-589-0802
  • Fax: 502-589-0805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3003622
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: