Provider Demographics
NPI:1154477123
Name:DE LEON FERGUSON, RAE JEAN
Entity Type:Individual
Prefix:MRS
First Name:RAE
Middle Name:JEAN
Last Name:DE LEON FERGUSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:RAE
Other - Middle Name:JEAN
Other - Last Name:DELEON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24743 W ILLINI ST
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85326-3376
Mailing Address - Country:US
Mailing Address - Phone:623-386-7631
Mailing Address - Fax:
Practice Address - Street 1:24743 W ILLINI ST
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85326-3376
Practice Address - Country:US
Practice Address - Phone:623-386-7631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11264171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ171W00000XMedicaid