=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851643100
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY LYNN FUGOK RD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2012
-----------------------------------------------------
Last Update Date | 05/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 N ACADEMY AVE # MC15-09
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17822-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-214-3223
-----------------------------------------------------
Fax | 570-271-7805
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | GEISINGER MEDICAL CTR 100 NORTH ACADEMY AVENUE, MC 15-09
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17822-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-214-3223
-----------------------------------------------------
Fax | 570-271-7805
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | DN002918
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 133VN1004X
-----------------------------------------------------
Taxonomy Name | Pediatric Nutrition Registered Dietitian
-----------------------------------------------------
License Number | DN002918
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------