Provider Demographics
NPI:1295378339
Name:FULCHER, LAKEN NICOLE (FNP)
Entity type:Individual
Prefix:
First Name:LAKEN
Middle Name:NICOLE
Last Name:FULCHER
Suffix:
Gender:F
Credentials:FNP
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 470
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39339-0470
Mailing Address - Country:US
Mailing Address - Phone:662-446-1972
Mailing Address - Fax:662-446-1039
Practice Address - Street 1:16569 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39339-2647
Practice Address - Country:US
Practice Address - Phone:662-773-5704
Practice Address - Fax:662-773-9463
Is Sole Proprietor?:No
Enumeration Date:2019-10-22
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR903535363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner