Provider Demographics
NPI:1962020560
Name:FUGATE, AMY JO (AGPCNP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JO
Last Name:FUGATE
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15730 N STATE HIGHWAY 130
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:IL
Mailing Address - Zip Code:62448-3273
Mailing Address - Country:US
Mailing Address - Phone:217-663-5414
Mailing Address - Fax:
Practice Address - Street 1:1000 PALM AVE
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-6031
Practice Address - Country:US
Practice Address - Phone:888-365-6271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-09
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209021558363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty