Provider Demographics
NPI:1235505108
Name:FERGUSON, BETHANY JOY WINFREY (FNP-BC)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:JOY WINFREY
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2321 N WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-5613
Mailing Address - Country:US
Mailing Address - Phone:309-680-7600
Mailing Address - Fax:309-681-8620
Practice Address - Street 1:2321 N WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-5613
Practice Address - Country:US
Practice Address - Phone:309-680-7600
Practice Address - Fax:309-681-8620
Is Sole Proprietor?:No
Enumeration Date:2015-08-14
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-013059363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209-013059OtherIL APN LICENSE