Provider Demographics
NPI:1902009772
Name:FUGO, JACQUELINE A (LPN, STNA)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:A
Last Name:FUGO
Suffix:
Gender:F
Credentials:LPN, STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168 LINDEN ST
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-2519
Mailing Address - Country:US
Mailing Address - Phone:330-221-8242
Mailing Address - Fax:
Practice Address - Street 1:168 LINDEN ST
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-2519
Practice Address - Country:US
Practice Address - Phone:330-221-8242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2729408171W00000X
OHPN. 129913164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No171W00000XOther Service ProvidersContractor