Healthcare Provider Details

I. General information

NPI: 1710928445
Provider Name (Legal Business Name): ANGELLA NICOLE FUGE ATC/R
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 NE 48TH AVE SUITE 700
HILLSBORO OR
97124-4904
US

IV. Provider business mailing address

17994 SW CAMAS ST
ALOHA OR
97006-4696
US

V. Phone/Fax

Practice location:
  • Phone: 503-681-4238
  • Fax:
Mailing address:
  • Phone: 503-888-7874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-AT-100293
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: