Provider Demographics
NPI:1134123649
Name:FULKERSON, NINA MICHAEL (APRN)
Entity type:Individual
Prefix:MRS
First Name:NINA
Middle Name:MICHAEL
Last Name:FULKERSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:401 E CHESTNUT ST
Mailing Address - Street 2:STE #510
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-5700
Mailing Address - Country:US
Mailing Address - Phone:502-589-0802
Mailing Address - Fax:502-589-0805
Practice Address - Street 1:2360 STONY BROOK DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-4018
Practice Address - Country:US
Practice Address - Phone:502-446-5462
Practice Address - Fax:502-394-3670
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY3003622363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100005460Medicaid
KYP4000040973Medicare PIN