Provider Demographics
NPI:1033746011
Name:FERGUSON, KELLI ENSLEY (CNA II)
Entity Type:Individual
Prefix:MS
First Name:KELLI
Middle Name:ENSLEY
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:CNA II
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:NICOLE
Other - Last Name:ENSLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNA I
Mailing Address - Street 1:108 BLAIR LN APT B
Mailing Address - Street 2:
Mailing Address - City:BESSEMER CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28016-9300
Mailing Address - Country:US
Mailing Address - Phone:704-913-8715
Mailing Address - Fax:
Practice Address - Street 1:2825 RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1018
Practice Address - Country:US
Practice Address - Phone:704-377-1647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-27
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC71763156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist