Healthcare Provider Details

I. General information

NPI: 1154760312
Provider Name (Legal Business Name): SAMANTHA FUGATE KENNEDY D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SAMANTHA ANN FUGATE

II. Dates (important events)

Enumeration Date: 06/21/2013
Last Update Date: 02/09/2026
Certification Date: 02/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 HASLETT RD
HASLETT MI
48840-8469
US

IV. Provider business mailing address

1660 HASLETT RD STE 1
HASLETT MI
48840-8469
US

V. Phone/Fax

Practice location:
  • Phone: 517-347-8420
  • Fax: 517-347-8420
Mailing address:
  • Phone: 517-347-8420
  • Fax: 517-347-8420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number5101020751
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: