Healthcare Provider Details

I. General information

NPI: 1053389320
Provider Name (Legal Business Name): LAUREL ELIZABETH FERGUSON L.D., R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S MAIN ST
BROOKSVILLE FL
34601-3320
US

IV. Provider business mailing address

300 S MAIN ST
BROOKSVILLE FL
34601-3320
US

V. Phone/Fax

Practice location:
  • Phone: 352-540-6800
  • Fax: 352-754-4088
Mailing address:
  • Phone: 352-540-6800
  • Fax: 352-754-4088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND 4805
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: