Provider Demographics
NPI:1003083692
Name:FUQUA, MARY MARIE (BS)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:MARIE
Last Name:FUQUA
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 BRECKENRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-1054
Mailing Address - Country:US
Mailing Address - Phone:270-686-7747
Mailing Address - Fax:270-852-2941
Practice Address - Street 1:1501 BRECKENRIDGE ST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-1054
Practice Address - Country:US
Practice Address - Phone:270-686-7747
Practice Address - Fax:270-852-2941
Is Sole Proprietor?:No
Enumeration Date:2008-05-13
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator