Healthcare Provider Details

I. General information

NPI: 1871980003
Provider Name (Legal Business Name): BRITTANY MOORE FUGATE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2015
Last Update Date: 05/19/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1484 LAKESIDE DRIVE
JACKSON KY
41339-6555
US

IV. Provider business mailing address

PO BOX 690
BEATTYVILLE KY
41311-0690
US

V. Phone/Fax

Practice location:
  • Phone: 606-666-9950
  • Fax: 606-666-9136
Mailing address:
  • Phone: 606-464-0105
  • Fax: 606-464-0152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number04480
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number04480
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: