Provider Demographics
NPI:1861667297
Name:FUQUA, KELLY MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:MARIE
Last Name:FUQUA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3659 W WEATHERBY DR
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70665-8719
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:920 1ST AVE
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70663-3425
Practice Address - Country:US
Practice Address - Phone:337-527-7034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-27
Last Update Date:2012-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200962207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1072907Medicaid