Healthcare Provider Details

I. General information

NPI: 1457951998
Provider Name (Legal Business Name): PERI MCKENZIE FERGUSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PERI MCKENZIE FERGUSON

II. Dates (important events)

Enumeration Date: 10/26/2020
Last Update Date: 04/20/2022
Certification Date: 04/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 W OLD SHAKOPEE RD
BLOOMINGTON MN
55438-2654
US

IV. Provider business mailing address

2194 HERITAGE LN N
NORTH SAINT PAUL MN
55109-1779
US

V. Phone/Fax

Practice location:
  • Phone: 507-353-3083
  • Fax:
Mailing address:
  • Phone: 619-616-0190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: