MEDICARE: NICOLE FERGUSON M.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	3998362	AZ

General Provider Information

NPI Number	:	1013208842
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE FERGUSON M.A.

Provider Business Mailing Address
First Line	:	2925 E BLACKHAWK DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85050-4721
Country	:	US
Telephone Number	:	480-221-7264
Fax Number	:

Provider Business Practice Location Address
First Line	:	2925 E BLACKHAWK DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85050-4721
Country	:	US
Telephone Number	:	480-221-7264
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/27/2011
Last Update Date	:	04/27/2011

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