Provider Demographics
NPI:1235670639
Name:NICOLE PURSIFULL FAMILY PRACTITIONER
Entity Type:Organization
Organization Name:NICOLE PURSIFULL FAMILY PRACTITIONER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP/OWNER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:PURSIFULL
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:606-269-6350
Mailing Address - Street 1:123 N 19TH ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLESBORO
Mailing Address - State:KY
Mailing Address - Zip Code:40965-2865
Mailing Address - Country:US
Mailing Address - Phone:606-269-6350
Mailing Address - Fax:
Practice Address - Street 1:123 N 19TH ST STE 2
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965-2865
Practice Address - Country:US
Practice Address - Phone:606-269-6350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-17
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1117450363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty