MEDICARE: KELLY FUGATE FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	20561	TN
2	363LF0000X	Family Nurse Practitioner	0024173176	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629442694
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY FUGATE FNP-C

Provider Business Mailing Address
First Line	:	1021 W OAKLAND AVE STE 310
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37604-2192
Country	:	US
Telephone Number	:	423-952-2111
Fax Number	:

Provider Business Practice Location Address
First Line	:	2000 BROOKSIDE DR FL 7
Second Line	:
City	:	KINGSPORT
State	:	TN
Zip	:	37660-4627
Country	:	US
Telephone Number	:	423-857-7011
Fax Number	:	423-857-7018

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/13/2015
Last Update Date	:	12/29/2025

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