Healthcare Provider Details

I. General information

NPI: 1932885332
Provider Name (Legal Business Name): STACY FERGUSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2023
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4825 MACCORKLE AVE SW STE F
SOUTH CHARLESTON WV
25309-1365
US

IV. Provider business mailing address

4825 MACCORKLE AVE SW STE F
SOUTH CHARLESTON WV
25309-1365
US

V. Phone/Fax

Practice location:
  • Phone: 304-346-9667
  • Fax:
Mailing address:
  • Phone: 304-346-9667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number61893
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: