Provider Demographics
NPI:1013208842
Name:FERGUSON, NICOLE (MA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 E BLACKHAWK DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-4721
Mailing Address - Country:US
Mailing Address - Phone:480-221-7264
Mailing Address - Fax:
Practice Address - Street 1:2925 E BLACKHAWK DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-4721
Practice Address - Country:US
Practice Address - Phone:480-221-7264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-27
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3998362174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist