Provider Demographics
NPI:1164107462
Name:FUGATT, JESSICA L (FNP-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:FUGATT
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 LEE ST
Mailing Address - Street 2:
Mailing Address - City:WINSLOW
Mailing Address - State:AZ
Mailing Address - Zip Code:86047-2603
Mailing Address - Country:US
Mailing Address - Phone:928-289-3396
Mailing Address - Fax:
Practice Address - Street 1:200 LEE ST
Practice Address - Street 2:
Practice Address - City:WINSLOW
Practice Address - State:AZ
Practice Address - Zip Code:86047-2603
Practice Address - Country:US
Practice Address - Phone:928-289-3396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-15
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ295511363LF0000X, 207Q00000X
AZTEMP295511207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily