Provider Demographics
NPI:1255223285
Name:FUDGE, MARIE ROSE
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:ROSE
Last Name:FUDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 446
Mailing Address - Street 2:
Mailing Address - City:HAINES
Mailing Address - State:AK
Mailing Address - Zip Code:99827-0446
Mailing Address - Country:US
Mailing Address - Phone:269-419-4297
Mailing Address - Fax:
Practice Address - Street 1:216 DALTON STREET
Practice Address - Street 2:PO BOX 90
Practice Address - City:HAINES
Practice Address - State:AK
Practice Address - Zip Code:99827
Practice Address - Country:US
Practice Address - Phone:907-766-6389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-15
Last Update Date:2025-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor