Provider Demographics
NPI:1336345768
Name:FERGUSON, KENNY (LPN)
Entity Type:Individual
Prefix:
First Name:KENNY
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 BACON STREET
Mailing Address - Street 2:
Mailing Address - City:PORT NORRIS
Mailing Address - State:NJ
Mailing Address - Zip Code:08349
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:261 CONNECTICUT DR
Practice Address - Street 2:SUITE 5
Practice Address - City:BURLINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08016-4177
Practice Address - Country:US
Practice Address - Phone:800-950-6066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NE01215300164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse