Provider Demographics
NPI:1801135694
Name:FUGATE, AMY LEIGH (FNP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LEIGH
Last Name:FUGATE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:415 BROAD ST
Mailing Address - Street 2:SUITE 410
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4263
Mailing Address - Country:US
Mailing Address - Phone:423-408-2960
Mailing Address - Fax:423-398-5500
Practice Address - Street 1:130 W RAVINE RD
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3837
Practice Address - Country:US
Practice Address - Phone:423-224-3836
Practice Address - Fax:423-224-5120
Is Sole Proprietor?:No
Enumeration Date:2013-02-14
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN17404363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I024363Medicare PIN
TN103I504365Medicare PIN