Healthcare Provider Details

I. General information

NPI: 1033731419
Provider Name (Legal Business Name): KRISTEN RAE FUGATE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2020
Last Update Date: 08/14/2021
Certification Date: 08/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 AIRPORT GARDENS RD STE 200
HAZARD KY
41701-9510
US

IV. Provider business mailing address

101 AIRPORT GARDENS RD STE 200
HAZARD KY
41701-9510
US

V. Phone/Fax

Practice location:
  • Phone: 606-629-3121
  • Fax:
Mailing address:
  • Phone: 606-629-3121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number1113647
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number3015889
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: