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
State | License ID | Taxonomies |
---|---|---|
KY | 3017412 | 363L00000X, 363LF0000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
KY | 1152520 | Other | KENTUCKY LICENSE |
KY | 3017412 | Other | APRN LICENSE |