Healthcare Provider Details

I. General information

NPI: 1639035413
Provider Name (Legal Business Name): KEISHA DAMORLEY FERGUSON FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/24/2025
Last Update Date: 12/24/2025
Certification Date: 12/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1114 ELM STREET NORTHEAST SUITE H
COVINGTON GA
30014
US

IV. Provider business mailing address

35 TERRELL LN
COVINGTON GA
30014-6904
US

V. Phone/Fax

Practice location:
  • Phone: 404-453-6561
  • Fax:
Mailing address:
  • Phone: 678-698-7387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2025087781
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: