Provider Demographics
NPI:1003242470
Name:FUGATE, SCHANDA
Entity Type:Individual
Prefix:
First Name:SCHANDA
Middle Name:
Last Name:FUGATE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:829 W MOUNTCASTLE ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37760-1829
Mailing Address - Country:US
Mailing Address - Phone:423-277-6615
Mailing Address - Fax:
Practice Address - Street 1:136 DAVIS LN
Practice Address - Street 2:
Practice Address - City:LA FOLLETTE
Practice Address - State:TN
Practice Address - Zip Code:37766-3118
Practice Address - Country:US
Practice Address - Phone:423-562-0760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-17
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4666225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant