Provider Demographics
NPI:1609228071
Name:FERGUSON, BROOKE
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:FERGUSON
Suffix:
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 1:900 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOPE
Mailing Address - State:AR
Mailing Address - Zip Code:71801-6525
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HOPE
Practice Address - State:AR
Practice Address - Zip Code:71801-6525
Practice Address - Country:US
Practice Address - Phone:870-722-6567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-08
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004800364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics