Healthcare Provider Details

I. General information

NPI: 1013654821
Provider Name (Legal Business Name): MICHELLE LYNN FERGUSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2022
Last Update Date: 01/18/2023
Certification Date: 01/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1018 IVAL JAMES BLVD STE C
RICHMOND KY
40475-8281
US

IV. Provider business mailing address

1018 IVAL JAMES BLVD STE C
RICHMOND KY
40475-8281
US

V. Phone/Fax

Practice location:
  • Phone: 859-575-1323
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3017462
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: