Healthcare Provider Details

I. General information

NPI: 1144494303
Provider Name (Legal Business Name): SUZETTE FERGUSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2008
Last Update Date: 04/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W HOSPITAL RD
FORT GORDON GA
30905-5741
US

IV. Provider business mailing address

3407 CAMAK DR
AUGUSTA GA
30909-9433
US

V. Phone/Fax

Practice location:
  • Phone: 706-231-2437
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License NumberRN088091
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: