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General NPI Number Information
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NPI Number | 1588517619
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Entity Type | Individual
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Provider Name | DESTINY MARIE FULLEN
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Gender | Female
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Dates
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Enumeration Date | 02/18/2026
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Last Update Date | 03/07/2026
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Provider Practice Location Address
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Address Line | 102 W JOHN ROWAN BLVD
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City | BARDSTOWN
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State | KY
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Zip | 40004-2663
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Country | US
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Telephone | 502-348-7880
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Fax |
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Provider Business Mailing Address
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Address Line | 108 BROOKSHADE DR
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City | MOUNT WASHINGTON
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State | KY
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Zip | 40047-5583
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Country | US
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Telephone | 502-759-0635
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 4047688
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number | 4047688
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License Number State | KY
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