Provider Demographics
NPI:1619203536
Name:KLEIN-FERGUSON, CONNIE RAE (RN)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:RAE
Last Name:KLEIN-FERGUSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:388 WEBB PIERCE ROAD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:OH
Mailing Address - Zip Code:45640
Mailing Address - Country:US
Mailing Address - Phone:740-288-7510
Mailing Address - Fax:
Practice Address - Street 1:388 WEBB PIERCE ROAD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:OH
Practice Address - Zip Code:45640
Practice Address - Country:US
Practice Address - Phone:740-288-7510
Practice Address - Fax:740-288-7510
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-28
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN301240163W00000X, 163WC0400X, 163WH1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WH1000XNursing Service ProvidersRegistered NurseHospice