Healthcare Provider Details

I. General information

NPI: 1497299770
Provider Name (Legal Business Name): CRYSTAL FERGUSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2016
Last Update Date: 12/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 JACKSON PIKE
GALLIPOLIS OH
45631-1560
US

IV. Provider business mailing address

PO BOX 390
HUNTINGTON WV
25708-0390
US

V. Phone/Fax

Practice location:
  • Phone: 304-429-1088
  • Fax:
Mailing address:
  • Phone: 304-429-1088
  • Fax: 304-696-1623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3010373
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number636444
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: