Healthcare Provider Details

I. General information

NPI: 1235548363
Provider Name (Legal Business Name): JESSICA FUQUA NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2014
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 BROAD AVE
GULFPORT MS
39501-3601
US

IV. Provider business mailing address

38 PASS RD STE A
GULFPORT MS
39507-3107
US

V. Phone/Fax

Practice location:
  • Phone: 228-865-1330
  • Fax: 228-865-1331
Mailing address:
  • Phone: 228-865-1330
  • Fax: 228-865-1331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number18863
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-02586
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number902207
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: