Provider Demographics
NPI:1114121167
Name:FERGUSSON, NICOLE L (NURSING)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:FERGUSSON
Suffix:
Gender:F
Credentials:NURSING
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-3007
Mailing Address - Country:US
Mailing Address - Phone:801-467-4056
Mailing Address - Fax:
Practice Address - Street 1:550 W 700 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-2227
Practice Address - Country:US
Practice Address - Phone:801-531-1857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2222843102163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health