Healthcare Provider Details

I. General information

NPI: 1669743530
Provider Name (Legal Business Name): BLAIRE M FERGUSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BLAIRE M WOUTERS CRNA

II. Dates (important events)

Enumeration Date: 01/24/2012
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 JOEL DR
FORT CAMPBELL KY
42223-5318
US

IV. Provider business mailing address

1846 WALNUT GROVE RD
CLARKSVILLE TN
37042-3847
US

V. Phone/Fax

Practice location:
  • Phone: 270-798-8400
  • Fax:
Mailing address:
  • Phone: 205-522-2118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA0839
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3016933
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-117275
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: