Provider Demographics
NPI:1467119057
Name:FULLER, BAILEY (APRN)
Entity Type:Individual
Prefix:
First Name:BAILEY
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 497
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:AR
Mailing Address - Zip Code:72006-0497
Mailing Address - Country:US
Mailing Address - Phone:870-347-2534
Mailing Address - Fax:870-347-1235
Practice Address - Street 1:3360 WAYNE SULLIVAN DR
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-0337
Practice Address - Country:US
Practice Address - Phone:270-443-9474
Practice Address - Fax:270-443-9477
Is Sole Proprietor?:No
Enumeration Date:2021-11-18
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3017412363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1152520OtherKENTUCKY LICENSE
KY3017412OtherAPRN LICENSE