Basic Information
| Provider Information | |||||||||
| NPI: | 1306097761 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FUGATE | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CLEM | ||||||||
| OtherFirstName: | LORI | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APRN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1306 VERSAILLES RD | ||||||||
| Address2: | 120 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405041796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592592635 | ||||||||
| FaxNumber: | 8592547874 | ||||||||
| Practice Location | |||||||||
| Address1: | 317 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WILMORE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403901323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8598580339 | ||||||||
| FaxNumber: | 8598580341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2008 | ||||||||
| LastUpdateDate: | 10/27/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | 3005740 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 363LF0000X | 3005740 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 7100176280 | 05 | KY | MEDICAID |