MEDICARE: KRISTA FUQUA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	201606762NP-PP	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	718569	OTHER	TX	LICENSE

General Provider Information

NPI Number	:	1013347582
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTA FUQUA

Provider Business Mailing Address
First Line	:	PO BOX 99371
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76199-0371
Country	:	US
Telephone Number	:	682-885-1855
Fax Number	:	682-885-7347

Provider Business Practice Location Address
First Line	:	1585 NW WASHINGTON BLVD
Second Line	:
City	:	GRANTS PASS
State	:	OR
Zip	:	97526-1049
Country	:	US
Telephone Number	:	541-474-5511
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/20/2013
Last Update Date	:	08/12/2021

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Directions to “ KRISTA FUQUA ” Practice Location

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