Provider Demographics
NPI:1851643100
Name:FUGOK, KELLY LYNN (RD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:FUGOK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:GEISINGER MEDICAL CTR
Mailing Address - Street 2:100 NORTH ACADEMY AVENUE, MC 15-09
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-0001
Mailing Address - Country:US
Mailing Address - Phone:570-214-3223
Mailing Address - Fax:570-271-7805
Practice Address - Street 1:GEISINGER MEDICAL CTR
Practice Address - Street 2:100 NORTH ACADEMY AVENUE, MC 15-09
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-0001
Practice Address - Country:US
Practice Address - Phone:570-214-3223
Practice Address - Fax:570-271-7805
Is Sole Proprietor?:No
Enumeration Date:2012-10-11
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN002918133V00000X, 133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered