Provider Demographics
NPI:1366866097
Name:FERGUSON, CLARA I
Entity Type:Individual
Prefix:
First Name:CLARA
Middle Name:
Last Name:FERGUSON
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 SE BEECH ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-4982
Mailing Address - Country:US
Mailing Address - Phone:615-974-9714
Mailing Address - Fax:
Practice Address - Street 1:184 SE BEECH ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-4982
Practice Address - Country:US
Practice Address - Phone:615-974-9714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-17
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12314310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility