Healthcare Provider Details

I. General information

NPI: 1861762304
Provider Name (Legal Business Name): GEORGIA RAYNE FERGUSON LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2011
Last Update Date: 12/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5029 ROOSEVELT WAY NE SUITE 101A
SEATTLE WA
98105-3697
US

IV. Provider business mailing address

5029 ROOSEVELT WAY NE SUITE 101A
SEATTLE WA
98105-3697
US

V. Phone/Fax

Practice location:
  • Phone: 206-547-4427
  • Fax: 206-547-3587
Mailing address:
  • Phone: 206-547-4427
  • Fax: 206-547-3587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60089157
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: