Provider Demographics
NPI:1952526907
Name:FERGUSON, ILENE ELIZABETH
Entity Type:Individual
Prefix:
First Name:ILENE
Middle Name:ELIZABETH
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 1:1925 BRANDON BROOK RD
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33954-3025
Mailing Address - Country:US
Mailing Address - Phone:813-662-6858
Mailing Address - Fax:813-662-6858
Practice Address - Street 1:1925 BRANDON BROOK RD
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33594-3025
Practice Address - Country:US
Practice Address - Phone:813-662-6858
Practice Address - Fax:813-662-6858
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL99468376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide