Provider Demographics
NPI:1669743530
Name:FERGUSON, BLAIRE M (CRNA)
Entity type:Individual
Prefix:
First Name:BLAIRE
Middle Name:M
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:BLAIRE
Other - Middle Name:M
Other - Last Name:WOUTERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:975 SMOOTS DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042-1689
Mailing Address - Country:US
Mailing Address - Phone:205-522-2118
Mailing Address - Fax:
Practice Address - Street 1:650 JOEL DR
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5318
Practice Address - Country:US
Practice Address - Phone:270-798-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-24
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-117275367500000X
AZCRNA0839367500000X
KY3016933367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered