Provider Demographics
NPI:1942793666
Name:FULLER, HALEY MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:MARIE
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 23229
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42304-3229
Mailing Address - Country:US
Mailing Address - Phone:270-688-1330
Mailing Address - Fax:270-688-1338
Practice Address - Street 1:1301 PLEASANT VALLEY RD STE 404
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303
Practice Address - Country:US
Practice Address - Phone:270-417-7515
Practice Address - Fax:270-417-7699
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1126430163W00000X
KY3012435363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse