Healthcare Provider Details

I. General information

NPI: 1619563418
Provider Name (Legal Business Name): AMBER C FERGUSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2020
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1439 SOUTH ST
LAKEWOOD NJ
08701-5440
US

IV. Provider business mailing address

1439 SOUTH ST
LAKEWOOD NJ
08701-5440
US

V. Phone/Fax

Practice location:
  • Phone: 732-523-2327
  • Fax: 732-544-0364
Mailing address:
  • Phone: 347-453-1935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number1740800713
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: