NPIMap

Individual provider Active NPI

Katlyn Bailey Clark-Fuqua, MD

  • Family Medicine Physician
  • Harriman, TN
National Provider Identifier
1952966467
Registry record updated Aug 26, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
71338 Issued in TN
Practice address
1855 Tanner Way Ste 200
Harriman, TN 37748-8332
Phone
(865) 374-6272
Fax
(865) 374-2100
NPI assigned
May 9, 2019
Last updated
Aug 26, 2024By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Aug 26, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 71338 TN Primary

Addresses

Primary practice location

1855 Tanner Way Ste 200
Harriman, TN 37748-8332

Mailing address

1855 Tanner Way Ste 200
Harriman, TN 37748-8332
Phone (865) 374-6272

Other identifiers 1

IdentifierTypeStateIssuer
Q095495MedicaidTN

Other names 1

  • Katlyn Bailey Clark Former name

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address clarkfuqua.katlyn@covenanthealth.cernerdirect.com

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TN
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20241015002882 TN Practitioner - Family Practice 3779984372 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
University of Louisville School of Medicine, 2021
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Covenant Medical Group IncGroup PAC ID 2860305463, 363 clinicians

Practice addresses (Care Compare)

1855 Tanner Way
Suite 220
Harriman, TN 37748-8332
Phone (865) 882-2442

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal or shaving of skin growth1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
71338TNMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Covenant Medical Group, Inc. Family Medicine CurrentSince Oct 1, 2024 Accepting new patients
Covenant Medical Group, Inc CurrentSince Oct 1, 2024 Accepting new patients

Locations

1855 Tanner Way
Ste 220
Harriman, TN 37748
Phone (865) 882-2442

Dept 888179
Knoxville, TN 37995

111 Clyde St
Loudon, TN 37774
Phone (865) 458-1554

Interoperability endpoints

  • Direct secure messaging: clarkfuqua.katlyn@covenanthealth.cernerdirect.com

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 5

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1557360000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1724630400000",
    "number": "1952966467",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1855 TANNER WAY STE 200",
            "city": "HARRIMAN",
            "state": "TN",
            "postal_code": "377488332",
            "telephone_number": "865-374-6272",
            "fax_number": "865-374-2100"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1855 TANNER WAY STE 200",
            "city": "HARRIMAN",
            "state": "TN",
            "postal_code": "377488332",
            "telephone_number": "865-374-6272",
            "fax_number": "865-374-2100"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLARK-FUQUA",
        "first_name": "KATLYN",
        "middle_name": "BAILEY",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2019-05-09",
        "last_updated": "2024-08-26",
        "certification_date": "2024-08-26",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "TN",
            "license": "71338",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "Q095495",
            "state": "TN"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "clarkfuqua.katlyn@covenanthealth.cernerdirect.com",
            "affiliation": "N",
            "address_1": "1855 Tanner Way Ste 200",
            "city": "Harriman",
            "state": "TN",
            "country_code": "US",
            "postal_code": "377488332",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "first_name": "KATLYN",
            "last_name": "CLARK",
            "middle_name": "BAILEY",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

Other providers in Harriman, TN

Sources for this page

Verify at the official NPI Registry.