Provider Demographics
NPI:1316488935
Name:PURSIFULL, NICOLE (NP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:PURSIFULL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 AIRPORT GARDENS RD STE 311
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-9529
Mailing Address - Country:US
Mailing Address - Phone:606-439-6978
Mailing Address - Fax:
Practice Address - Street 1:2145 US HIGHWAY 25 E
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965-1874
Practice Address - Country:US
Practice Address - Phone:606-248-8503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-15
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3011189363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily