Healthcare Provider Details

I. General information

NPI: 1316488935
Provider Name (Legal Business Name): NICOLE PURSIFULL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2017
Last Update Date: 08/03/2020
Certification Date: 08/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2145 US HIGHWAY 25 E
MIDDLESBORO KY
40965-1874
US

IV. Provider business mailing address

100 AIRPORT GARDENS RD STE 311
HAZARD KY
41701-9529
US

V. Phone/Fax

Practice location:
  • Phone: 606-248-8503
  • Fax:
Mailing address:
  • Phone: 606-439-6978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3011189
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: