Healthcare Provider Details

I. General information

NPI: 1629586946
Provider Name (Legal Business Name): ASHLEY FERGUSON APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2018
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2502 E EMPIRE ST
BLOOMINGTON IL
61704-3738
US

IV. Provider business mailing address

101 W UNIVERSITY AVE
CHAMPAIGN IL
61820-3981
US

V. Phone/Fax

Practice location:
  • Phone: 217-366-4407
  • Fax:
Mailing address:
  • Phone: 217-366-4407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number209.016909
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number277002498
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: