Provider Demographics
NPI:1922571231
Name:FERGUSON, LANICE ELAINE
Entity Type:Individual
Prefix:
First Name:LANICE
Middle Name:ELAINE
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 1:270 CARPENTER DR STE 400
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-4933
Mailing Address - Country:US
Mailing Address - Phone:678-460-0345
Mailing Address - Fax:678-460-0350
Practice Address - Street 1:1238 VIENNA CT
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:GA
Practice Address - Zip Code:30228-6452
Practice Address - Country:US
Practice Address - Phone:404-797-4495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC006278390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program