Provider Demographics
NPI:1356816565
Name:FERGUSON, BETHANY (RD, LD, IBCLC)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:RD, LD, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1022 E COUNTY ROAD 2770
Mailing Address - Street 2:
Mailing Address - City:NIOTA
Mailing Address - State:IL
Mailing Address - Zip Code:62358-2018
Mailing Address - Country:US
Mailing Address - Phone:319-316-2004
Mailing Address - Fax:
Practice Address - Street 1:1022 E COUNTY ROAD 2770
Practice Address - Street 2:
Practice Address - City:NIOTA
Practice Address - State:IL
Practice Address - Zip Code:62358-2018
Practice Address - Country:US
Practice Address - Phone:319-316-2004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-04
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.007516133V00000X
L-311161174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered