Provider Demographics
NPI:1376900118
Name:FERGUSON, DJINN GOLL (LPN)
Entity Type:Individual
Prefix:
First Name:DJINN
Middle Name:GOLL
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:ANTHONY
Other - Middle Name:LARAY
Other - Last Name:FERGUSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9040 REID STREET
Mailing Address - Street 2:MADIGAN ARMY MEDICAL CENTER ATTN: MCHJ-CLQ-C
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-1100
Mailing Address - Country:US
Mailing Address - Phone:253-968-1110
Mailing Address - Fax:877-874-1031
Practice Address - Street 1:9040 REID STREET
Practice Address - Street 2:MADIGAN ARMY MEDICAL CENTER ATTN: MCHJ-CLQ-C
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-1100
Practice Address - Country:US
Practice Address - Phone:253-968-1110
Practice Address - Fax:877-874-1031
Is Sole Proprietor?:No
Enumeration Date:2016-01-25
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX230912164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse