Healthcare Provider Details

I. General information

NPI: 1104736156
Provider Name (Legal Business Name): DALIAH FERGUSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 EAGLES LANDING PKWY
STOCKBRIDGE GA
30281-5092
US

IV. Provider business mailing address

123 EAGLES LANDING PKWY
STOCKBRIDGE GA
30281-5092
US

V. Phone/Fax

Practice location:
  • Phone: 203-218-6187
  • Fax:
Mailing address:
  • Phone: 203-218-6187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: