Basic Information
| Provider Information | |||||||||
| NPI: | 1619922481 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FUGAZY | ||||||||
| FirstName: | LENNI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1041 WYOMI DR | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339192635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393219055 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1611 W HARRISON ST # 400 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606124861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122434244 | ||||||||
| FaxNumber: | 3129421517 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 01/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9104242 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | 085002149 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1633878 | 01 | IL | BCBS PPO | OTHER | P00990032 | 01 | IL | RR MEDICARE | OTHER | 292866300 | 05 | FL | MEDICAID |