Healthcare Provider Details

I. General information

NPI: 1760155865
Provider Name (Legal Business Name): JESSICA K FUGGITI AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2021
Last Update Date: 07/26/2021
Certification Date: 07/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 RIGBY LAKE DR STE C
RIGBY ID
83442-5117
US

IV. Provider business mailing address

3446 S 15TH E
IDAHO FALLS ID
83404-8262
US

V. Phone/Fax

Practice location:
  • Phone: 208-522-6335
  • Fax: 208-522-0550
Mailing address:
  • Phone: 208-522-6335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberAUD-4886
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: