MEDICARE: MRS. PAMELA BROCK FERGUSON RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	R853647	MS

General Provider Information

NPI Number	:	1750598199
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. PAMELA BROCK FERGUSON RN

Provider Business Mailing Address
First Line	:	300 LINDEN ST
Second Line	:
City	:	NEW ALBANY
State	:	MS
Zip	:	38652-2427
Country	:	US
Telephone Number	:	662-534-5347
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 LINDEN ST
Second Line	:
City	:	NEW ALBANY
State	:	MS
Zip	:	38652-2427
Country	:	US
Telephone Number	:	662-534-5347
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	07/08/2007

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