Healthcare Provider Details

I. General information

NPI: 1235670639
Provider Name (Legal Business Name): NICOLE PURSIFULL FAMILY PRACTITIONER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2017
Last Update Date: 03/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 N 19TH ST STE 2
MIDDLESBORO KY
40965-2865
US

IV. Provider business mailing address

123 N 19TH ST
MIDDLESBORO KY
40965-2865
US

V. Phone/Fax

Practice location:
  • Phone: 606-269-6350
  • Fax:
Mailing address:
  • Phone: 606-269-6350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1117450
License Number StateKY

VIII. Authorized Official

Name: NICOLE PURSIFULL
Title or Position: FNP/OWNER MANAGER
Credential: FNP
Phone: 606-269-6350