Provider Demographics
NPI:1881281186
Name:FERGUSON, WANDA GALE (RN, MSN)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:GALE
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:RN, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1633 ALCATRAZ AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703-2611
Mailing Address - Country:US
Mailing Address - Phone:216-333-9678
Mailing Address - Fax:
Practice Address - Street 1:7200 BANCROFT AVE # 204
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-2403
Practice Address - Country:US
Practice Address - Phone:510-577-3517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-22
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA580416163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice