Healthcare Provider Details

I. General information

NPI: 1316862576
Provider Name (Legal Business Name): ALYSA FUGAL LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 WALTERS RD
BARNESVILLE GA
30204-3391
US

IV. Provider business mailing address

127 WALTERS RD
BARNESVILLE GA
30204-3391
US

V. Phone/Fax

Practice location:
  • Phone: 406-579-6133
  • Fax:
Mailing address:
  • Phone: 406-579-6133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT004480
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: