Healthcare Provider Details

I. General information

NPI: 1417930199
Provider Name (Legal Business Name): STACY FERGUSON PTA, AA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 01/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 W CLARK RD
CONNELL WA
99326-9700
US

IV. Provider business mailing address

PO BOX 829
CONNELL WA
99326-0829
US

V. Phone/Fax

Practice location:
  • Phone: 509-234-2021
  • Fax: 509-234-9200
Mailing address:
  • Phone: 509-234-2021
  • Fax: 509-234-9200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberP1 60040866
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: