Provider Demographics
NPI:1629442694
Name:FUGATE, KELLY (FNP-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FUGATE
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 1:351 COURT ST
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24210-2921
Mailing Address - Country:US
Mailing Address - Phone:276-676-3360
Mailing Address - Fax:276-676-2170
Practice Address - Street 1:351 COURT ST
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24210-2921
Practice Address - Country:US
Practice Address - Phone:276-676-3360
Practice Address - Fax:276-676-2170
Is Sole Proprietor?:No
Enumeration Date:2015-11-13
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20561363LF0000X
VA0024173176363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1629442694Medicaid
VA1629442694Medicaid