Healthcare Provider Details

I. General information

NPI: 1114121167
Provider Name (Legal Business Name): NICOLE L FERGUSSON NURSING
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 W 700 S
SALT LAKE CITY UT
84101-2227
US

IV. Provider business mailing address

609 WILSON AVE
SALT LAKE CITY UT
84105-3007
US

V. Phone/Fax

Practice location:
  • Phone: 801-531-1857
  • Fax:
Mailing address:
  • Phone: 801-467-4056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number2222843102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: